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Abstract—A digital inclusion kit to expand the frontiers of

computing technology in health and higher education is described. In Telemedicine (TM), its goal is to reach underserved zones, rural and urban, with mobile technology, which allows data acquisition of patients unable to assist to specialized medical centers. Mobile devices with portable acquisition systems, such as ECG or arterial blood pressure, allows the building of a clinic database for use in preventive medicine (cardiovascular diseases, diabetes and cancer). The idea here is to move data, not people. As a backbone, a Virtual Cluster (VC) is constructed, sharing all patient data between educational and research communities in higher education.

Index Terms— Digital inclusion, telemedicine, mobile devices,

clinic database.

I. INTRODUCTION

We describe the construction of a digital inclusion kit to expand the frontiers of computing technology in health and higher education to promote research and development in Latin America. By computing technology we mean any digital activity such as database searches and queries, high performance simulations, visualization, access to computer-controlled laboratory experiments, among others. In particular, in a Telemedicine (TM) context, its aim is to reach underserved zones, both rural and urban, with mobile technology, which allows diverse data acquisition of patients or whole communities, who are located nearby or in distant geographical areas, but are not able to assist periodically to specialized medical centers and hospitals. The use of mobile devices (MD) in conjunction with portable acquisition systems, such as ECG or arterial blood pressure, allows the building of a clinic database which could be analyzed and processed to apply preventive medicine in cardiovascular diseases, diabetes and cancer, among others. To do this, we propose the deployment of a Virtual Cluster (VC) to share all patient data between educational and research communities, and bring computer resources to them. In fact, VC expands the boundaries of distributed computing among scientists and students by notably simplifying the task of performing computational science research, a task presently considered

This work is supported by Microsoft under RFP2006 Digital Inclusion. The authors are with the Laboratory for Complex systems, Computer

Science Department, FCEyN, UBA. (e-mail: marshalg@mail.retina.ar, soba@cnea.gov.ar ).

extremely difficult and time consuming for non computer scientists. Moreover, VC has much wider applications which can be summarized by noting that what the Web did for communication, VC endeavor to do for computing. In the area of health, TM is a growing field, allowing a fast link between physicians and patient, while in higher education, VC is a new idea with great potential for performing distributed computing in a transparent way across multiple administrative domains.

The applications of TM include inter consultation between physicians, sharing of medical records (including images and physiological signals such as ECG, X-rays, among others), and medical education at both medical student and postgraduate levels (continuing medical education and discussion of clinical cases).

The last mile of TM can be reached with the Digital Inclusion Technology Resource Kit (DITRK), consisting in a Mobil Phone / PDA (touch screen) I-mate K-Jam, Visual Studio 2005 and .NET Compact Framework Rapid Development Kit that provides a framework for the development of mobile applications, with enormous potential for acquisition of patient’s data in the field. DITRK will permit a substantial reduction of traveling costs; preventive medicine will be improved; in case of epidemic alerts measurements could be rapidly taken, and so forth. The main idea here is to move data, not patients. In addition with the DITRK, we plan to attach the MD with a GPS, in order to get geographical position while taking information about patients. It could be used to determine risk zones, or particular case regions. The project relevance, if successful, lies in health improvements for the population and therefore economic and social advancement. Besides that, real-time applications transmitting audio and video constitutes a suitable way to develop a real-time infrastructure for telemedicine where audio, video, data, signals and images are shared at different locations, through a link with a database that manages all the information, such as storage and retrieval of medical records and studies. Additionally, a general idea about therapeutic compliance and medical treatment of different pathologies, in this case arterial hypertension, will be also evaluated. Having all these data analyzed, educational orientation for both medical and citizens could be engaged with the aim of reducing cardiovascular risk, optimizing quality of life and diminishing morbid-mortality with nutritional and pharmacological treatment.

Digital Inclusion kit in health and higher education

Soba A., Panelli A, Perez Rodriguez M., Risk M., Suarez J. P., Marshall G.

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II. GENERAL DESCRIPTION

A. Motivations of the work

In Health sciences, with the progress in computer tools and communications, the use of information has been improved, especially in statistics and prevention. The data obtained was used for several campaigns and health policies against different diseases, like those related to cardiovascular and cerebral risk. The campaign basically consists in a first stage compiling information in a certain population group, e.g. male adults or female between 18-65 years old, etc; then, a publicity campaign against smoking and bad alimentary habits is implemented; concomitantly, periodical medical visits to the population group is carried over and finally, new information is gathered, with the purpose of remaking statistics to check the policy implementation success [1][2].

Russia

Romania

Poland

Argentina

Colombia

Scotland

Finland

Germany

United States

Mexico

Austria

Canada

Spain

Japon

0 500 1000 1500 2000 2500

Mens Age 35-74 Total Deaths Stroke deaths Coronary Heart Disease (CHD) Cardiovascular Disease (CVD)

Rate per 100.000 Population

Coun

tries

(Rev

ised

2005

)

Figura 1: The graphic shows death rates from cardiovascular diseases in several countries, including Argentina (from [1]).

All these projects are relativity easy to implement in cities and urban zones, because they are closer to communication centers and health institutes in a network of professional relations. This is not the case in rural zones where neither networks nor main and complex hospitals exist. If hospitals exist they do not possess a critical mass of physicians and health scientists to justify the creation of communications and research centers (under a pure economic point of view) for health or any other applications. In this context, the development of a mobile kit with internet connectivity will allow communication of those small centers and physicians with the complex national network and with government or non government organizations. In this way, new powerful technologies, such as phones or a PDA, plus Internet access via General Packet Radio Service (GPRS) service or Wi-Fi (if available) provides a way to connect those small units into national health programs nets. For this end it is necessary to

build specific tools and applications to integrate and store information, such as a clinic database (stored in a server allowing instant access for data manipulation and data mining).

An example of this program is the National Survey for tracking cardiovascular risks1 factors, an observational study carried over in Argentina with the objective to search and register changes in the cardiovascular risk factor (CRF) by pharmacological interventions or not. This study will make an evaluation of the CRF state of knowledge and the presence of other pathologies in the patients. All the information will be gathered during five visits of the doctor and electronically registered to be latter analyzed. The analysis will be carried over in two stages. In the first one, the prevalence of cardiovascular risk factor and habits of the patient, in reference to the geographical position, educative level, age and sex will be analyzed; the degree of knowledge of the CRF and the treatments against it will be analyzed too. In the second stage, the effects on the CRF of the correction in the alimentary habits and physical activities, the patient diet adherence, the pharmacological treatments and the patients level of commitment to the designed programs, will be studied. All this information will be gathered in a clinic database.

B. DITRK

The main objective in the context of TM is the development of a DITRK based application which allows the patient data acquisition. The information to be acquired consists in a complete data form to create or upgrade (periodical visits are envisaged) a patient case history, perform an ECG, an arterial blood pressure measurement, get the geographical position (using a Global Positioning System (GPS)) in order to elaborate a demographic map, and get video or photo imaging of the patient housing, that could help to determine general sanitary conditions.

Figure 2: The communication ways between physicians and database using Telephones and Internet

1 Encuesta Nacional y Seguimiento de factores de riesgo cardiovascular

(ENASE)

3

The data will be transmitted to a central server using Wi-Fi

in urban zones if available, or GPS/GPRS in other cases. When no communication is available, the information is stored and sent later, when a service becomes available, or synchronized directly with the server, when the mobile device (MD) returns to the center. The MD platform will have the following uses (see figure 2).:

A) Real-time connection of patients with distant medical

facilities: this will need the sharing of the in situ acquired data (by portable medical equipment): physiological data, video and images. The proposed development includes a comprehensive display of the medical records, new data and studies of patients, together with an integrated interface of audio and video.

B) Medical education use: in this case the application will exploit the wireless-enabled system; the application in medical education will take advantage of the multimedia capabilities of DITRK developments.

As an example of a possible scenario of this application we mention the link between a physician or a paramedic and the main medical office, in the first one a physician or paramedic is in front of the patient, while checking his/her medical record, the physician is able to make an inter consultation with the main medical office in real time, then he/she performs an electrocardiogram, measures the arterial blood pressure, and finally shares all this data with the distant medical office for a more experienced opinion; this case is useful for postgraduate medical training such as fellowships and internships.

C. DataBase

Clinic Database stores patient information related to health status, cardiovascular risks through measurable variables such as: arterial pressure, congenital illness treatments, diets, ECG’s, medical images. Geographical region is taken into account for analysis of regional decreases and prevention policies. This information is available for physician’s consultation and for statistics. Database access is through web services and mobile systems including GPRS.

Figura 3: The database gets information directly from different devices

The database is built using SQL 2005 tools and works in a

server which provides instant access for users, for inserting more registries or changing information about theirs patients or themselves. The information is available for special purposes such as making statistical analysis and search of zonal dates for the implementation of different policies and treatment. (Figure 3).

All records are stored in the database as an XML file complying with HL7 specification format

In other way, the database allows a complete registration of information of each patient, in a first approach, in relation with cardiovascular factor risks, but with possibilities of extending these capabilities to other type of information, like images, , and any other information allowing electronic format.

D. Investigator Unit

The investigator unit is composed by a Mobile phone and a handheld device, the use is intended primarily by a physician to gather patient’s information in situ through a specially developed application running on the mobile phone (Windows mobile); information such as personal data will be incorporated to his/her medical record. The handheld device is an ECG amplifier, connected to the Mobile phone using a bluetooth interface, this will allow the acquisition of an ECG, later to be stored as part of the patient’s medical record. In the case of GPS or GPRS services available in situ, the collected records are sent to the main database server; in other cases case, the records are temporarily stored in the mobile phone and later sent to the server. The following figure shows the block diagram of the investigator unit:

Figure 4: an example of the investigator unit application.

E. Virtual cluster

VC is a distributed computing system executing distributed applications inside virtual machines installed on all nodes of a grid; it has central administration and remote resource control,

SQL Server 2005Data Storage of XMLs

Sending information - Interacting with database

<xml><name>John Smith</name>

</xml>

XML File

using de HL7

standard

with the data

of patient

SQL Server 2005Relational Data Model

<xml></xml>

Investigator

Patient

XML-WebService

<xml></xml>

B

A

C

D Name: John Smith varchar(50)

DNI: 27281664 numeric(9)

Age : 27 numeric(3)

...

���������

GP

S L

ink

GPS Module

A/D Module

Bluetooth Module

µController

ECG Electrodes

Smartphone – Investigator Unit

Instrumentation Amplifier

Bluetooth Link

Mobile Application

Patient

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uses MS Virtual Server 2005 providing "image files" for system deployment. Connection nodes-central server is through VPN.

In relation to VC, the main goal is the construction of a preliminary distributed computing system to execute distributed applications inside virtual machines installed at all nodes of the grid. It will have a central administration and remote resource control, which will schedule tasks to be executed in different nodes. Using Microsoft Virtual Server 2005 and providing "image files" for system deployment will provide a consistent and stable operating system and application software environment. By running tasks inside virtual machines the system ensures that the user desktop system (which has an installed virtual machine working as a node of the distributed system) is completely isolated from any process run inside the system, and vice versa. While running an application in this distributed system, it could be paused, and resume later, in the same way as it is possible to pause and restart virtual machines. To ensure data privacy, the connection between nodes and central server will be done using VPN.

F. Status of the development

Hardware: At the moment was developed and tested the instrumentation amplifier for ECG (one channel), the A/D module and the micro controller, connected with the bluetooth module; this development is at the level of experimental circuit, the next step is to increment the number of ECG channels, and then to fabricate the final circuit (printed circuit board).

Software: At the moment were implement a .NET web services for information transference and recuperation, the use of .NET web services from the Pocket PC device, a stored procedures through Assemblies technologies from SQL Server 2005 and the use of XML technology for the interchanging and modeling of information between devices and the server[8]. Besides that we were working in the implementation of a security model in the .NET web services, starting its development from a WCF and a web portal for tracking researchers in ASP.NET 2.0. All the communication will be compatible with the Standard HL7 [6,7].

III. DISCUSSION

DITRK in a Telemedicine context allows the use of medical

information exchanged from one site to another via electronic communications to improve patient health status. Transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education are all considered. To do that, it is necessary the transmission of health related data in a safe and reliable way, with guaranteed patient confidentiality. The same system that protects privacy of patient data has the added effect of additionally guaranteeing the integrity and authenticity of the information transmitted.

Another goal of the DITRK is to join portable equipment, friendly software and secure communication and data storing. All centers that currently use the system are integrated into a telemedicine network that creates a virtual medical and scientific community.

The end users of this system will be physicians and students, at the non governmental organization (NGO), using the system during their normal practice and or research. This development may have a social impact on the community in the city of Buenos Aires, and has a potential of being replicated in other areas of the NGO or other hospitals in the city, as long the system demonstrates to be useful in the regular clinical practice and in the educational application.

REFERENCES

[1] Thom T , Haase N, Rosamond W, Howard VJ, et al. Heart Disease and Stroke Statistics--2006 Update. A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2006.

[2] Heart Disease and stroke Statistics, 2006, American heart association. http://www.americanheart.org/

[3] http://www.paho.org/ [4] Criado A., Tarin A. Velasco E., Piedra R. “Factores de riesgo

concomitantes en una ampli muestra de pacientes hipertensos”, XX reunión nacional de la sección de cardiología preventiva y rehabilitación., Zaragoza, España.

[5] www.comitas.es [6] Health Level Seven [ http://www.hl7.org/ ] [7] Gomez, A., et al. Implementación de un sistema demensajeria

electrónica -HL7- para la integración de un sistema multiplataforma. in 4to Simposio de Informática en Salud - 30 JAIIO. 2001. Buenos Aires, Argentina: SADIO.

[8] Extensible Markup Language (XML). 2003, World Wide Web Consortium (W3C).