KHO YEH YUAN

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KOLEJ UNIVERSITI TEKNOLOGI TUN HUSSEIN ONN

BORANG PENGESAHAN STATUS TESIS* JUDUL: WEB-BASED INTERFACE SYSTEM FOR BEDSIDE MONITOR

SESI PENGAJIAN: 2004/2005

Saya KHO YEH YIIAN (HURUF BESAR)

mengaku membenarkan tesis (PSM/Saij ana/Doktor Falsafah)* ini disimpan di Perpustakaan dengan syarat-syarat kegunaan seperti berikut:

1. 2. 3.

4.

Tesis adalah hakmilik Kolej Universiti Teknologi Tun Hussein Onn. Perpustakaan dibenarkan membuat salinan untuk tujuan pengajian sahaja. Perpustakaan dibenarkan membuat salinan tesis ini sabagai pertukaran antara institusi pengajian tinggi. **Sila tandakan { / )

1 | SULIT (Mengandungi maklumat yang berdaijah keselamatan atau kepentingan Malaysia seperti yang termaktub di dalam (AKTA RAHSIA RASMI 1972)

| | TERHAD (Mengandungi maklumat TERHAD yang telah ditentukan oleh organisasi/badan di mana penyelidikan dijalankan)

1 V 1 TIDAK TERHAD

Disahkan oleh

(TANDATANGA^ PENULIS) (TANDAT/ik(MN PENYELIA)

Alamat tetap: 18. PERSIARAN 16. PERSIARAN BROOKE, 96000 SIBU.

PROF DR HASHIM BIN SAIM Nama Penyelia

SARAWAK.

Tarikh: 28 MAC 2005 Tarikh: 28 MAC 2005

CATATAN: * Potong yang tidak berkenaan. ** Jika tesis ini SULIT atau TERHAD, sila lampirkan surat daripada pihak

berkuasa/organisasi berkenaan dengan menyatakan sekali sebab dan tempoh tesis ini perlu dikelaskan sebagai SULIT atau TERHAD.

• Tesis dimaksudkan sebagai tesis bagi Ijazah Doktor Falsafah dan Saijana secara penyelidikan, atau disertasi bagi pengajian secara keija kursus dan penyelidikan, atau Laporan Projek Saijana Muda (PSM).

"Saya/Kami akui bahawa saya/kami telah membaca karya ini dan pada pandangan

saya/kami karya ini adalah memadai dari segi skop dan kualiti untuk tujuan

pengaugerahan Ijazah Saijana Kejuruteraan (Elektrikal)."

Tandatangan

Nama Penyelia I

Tarikh

Tandatangan

Nama Penyelia II

Tarikh

Profesor Dr. HWhim Bin Saim

28 Mac 2005

Soon Chin Fhong

28 Mac 2005

WEB-BASED INTERFACE SYSTEM FOR

BEDSIDE MONITOR

KHO YEH YUAN

A thesis submitted

in fulfillment of the requirements for the award of the

Degree of Master of Engineering (Electrical)

Faculty of Electrical and Electronic Engineering

Kolej Universiti Teknologi Tun Hussein Onn

MARCH, 2005

"No part of the study was covered by copyright. References of information obtained

from other source are specially quoted, otherwise the rest of the information

presented through this study is the sole work and experimentation carried out by the

author"

Signature

Author

Date

KHO YEH YTDLAN

28 March 2005

for my beloved parents, brothers and Chee Kiong, may God shower uncountable blessings upon all of you

ACKNOWLEDGEMENT

I would like to express my sincere gratitude to Prof. Dr Hashim bin Saim, my

supervisor and Mdm Soon Chin Fhong, my co-supervisor for their invaluable

guidance and advice throughout this research and all of my work with them and for

helping to move this process forward as quickly as possible. I would like to thank

Mr. Tang Tung Yan for providing input and advices. My parents have always been a

great source of encouragement in believing that I can accomplish whatever I want.

For my beloved late brother Yeh Wei, I would also like to thank you for everything.

I would like to take this opportunity to thank also my husband, Mr Sia Chee

Kiong for his patience with me all this while. In addition, I would like to thank

others who have indirectly contributed to the completion of this research such as the

medical laboratory technician, Mr. Ahyat for providing help whenever I needed to.

And also to all my friends, a big thank you to all of you for being my "patients".

There are also many other people that have provided me help and support and one

time or another that I should also thank, but the list would grow too long.

Many thanks and good luck to everyone.

ABSTRACT

From face-to-face consultation to medicine at a distance, technology is

changing the way medical services are delivered to the people. We are going into an

era where the information is being digitized to be stored in a database. This is done

in order to reduce information overlap and redundancy that are the main problems

the health care sector are facing right now. More hospitals in other more advanced

countries are going paperless. In order to provide better services to the critically ill

patients in the ICU or CCU, a data acquisition program is developed for the

acquisition of vital signs monitored in the critical care units. This work discusses the

work done in extracting the data and signal from patient monitor BSM 8800 to the

computer. The data are acquired using RS232C Interface Protocol. The vital signs

acquired include oxygen saturation (SaCh), heart rate (HR), electrocardiograph

(ECG) signal, non-invasive blood pressure (NIBP), respiration rate (RR),

temperature (TEMP) and end tidal carbon dioxide (PETCO2 or ETCO2). Ventricular

Premature Contraction (VPC), ST level and arrhythmia information are also acquired

and displayed to provide a more thorough information on the condition of the

patients. Alarm detection is also programmed so that in critical conditions the vital

signs will be displayed in red for extra caution. An ECG user control is designed

and embedded in the web page in order to convert and plot the ECG waveform from

hexadecimal values sent from the bedside monitor. The user control has been tested

its accuracy and proved its validity to reconstruct the original ECG waveform. Basic

patient information can also be seen from the graphical user interface (GUI) that has

been developed. Physicians and medical practitioners have to register with the

system before gaining access to the system and only the physician-in-charge of the

patient can see the more intricate details of the patient.

ABSTRAK

Teknologi sedang mengubah cara peijumpaan pesakit dengan doktor secara

konvensional kepada cara rawatan dari lokasi lain sedikit demi sedikit. Kita sedang

menuju ke era di mana maklumat ditukar kepada bentuk digital untuk disimpan

dalam pangkalan data. Ini adalah bertujuan mengurangkan informasi dan maklumat

yang sama difailkan dua kali. Sektor perubatan kini sedang menghadapi masalah

perlapisan data serta data lapuk yang tidak dikemaskinikan. Hospital di negara-

negara maju telahpun lama mengaplikasikan cara penyimpanan rekod secara digital

untuk mengelakkan pembaziran kertas. Bagi memberikan rawatan yang lebih baik

kepada pesakit-pesakit di unit-unit kecemasan, satu program untuk mendapatkan

data pesakit untuk pemeriksaan doktor dan jururawat dibangunkan. Tesis ini

membincangkan keija yang dibuat untuk mendapatkan data tersebut daripada BSM

8800 kepada komputer. Data didapatkan melalui protokol RS232C yang

membolehkan komunikasi antara alatan dengan komputer. Data yang didapatkan

termasuk kepekatan oksigen (Sa02 atau Sp02), kadar denyutan (HR),

elektrocardiograf (ECG), tekanan darah (NIBP), kadar respirasi (RR), suhu badan

(TEMP) dan kepekatan karbon dioksida dalam darah (ETC02 atau PETC02).

Kontraksi ventrikel awalan (VPC), tahap ST dan maklumat mengenai ECG yang

tidak normal turut didapatkan bagi mengetahui keadaan pesakit yang lebih

menyeluruh. Di kala teijadinya kecemasan, data akan terpapar dalam warna merah.

Satu program bagi menukarkan maklumat dalam bentuk heksa kepada voltan ECG

yang sepatutnya dibangunkan. Ia diuji dalam ketepatannya dan terbukti bahawa

ianya boleh dipercayai untuk menghasilkan gelombang ECG yang sama seperti yang

sebenar. Maklumat mengenai pesakit serta doktor yang merawat terdapat dalam

laman web yang dihasilkan. Doktor haruslah mendaftarkan diri sebelum boleh

mengakses laman web tersebut. Hanya doktor yang bertanggungjawab terhadap

seseorang pesakit boleh membaca maklumat pesakit yang lebih terperinci.

CONTENTS

CHAPTER ITEM PAGE

TITLE PAGE i

TESTIMONY ii

DEDICATION iii

ACKNOWLEDGEMENT iv

PAPERS PUBLISHED ARISING FROM THIS v

WORK

ABSTRACT vi

ABSTRAK vii

CONTENTS viii

LIST OF TABLES xiii

LIST OF FIGURES xv

LIST OF ABBREVIATIONS xvii

LIST OF APPENDICES xix

I INTRODUCTION

1.1 Background 1

1.2 Definition of Tide 3

1.3 Problem Statement 4

1.4 Objectives 6

1.5 Scope of Work 6

1.6 Proposed Method 12

1.7 Thesis Organization 12

II AN OVERVIEW OF VITAL SIGNS

MONITORED IN ICU/CCU

2.1 Vital Signs in the ICU/CCU 14

2.2 Electrocardiograph 14

2.3 Pulse / Heart Rate 18

2.4 Oxygen Saturation 18

2.5 Respiration Rate 19

2.6 End Tidal Carbon Dioxide 19

2.7 Non Invasive Blood Pressure 21

2.8 Temperature 22

2.9 ST Level and Ventricular Premature 23

Contraction

2.10 Brief Overview of the Conditions in ICU/CCU 24

2.11 Conclusion 26

III REVIEW OF LITERATURES

3.1 Introduction to Telemedicine 27

3.2 Wireless Technologies 31

3.3 Components in Telemedicine Applications 36

3.3.1 Computer Based Records and Critical 36

Care Databases

3.3.2 User Interface 41

3.3.3 Systems Integration and Standards 42

3.3.4 Telemedicine Architecture 43

3.4 Requirements for Web-based Systems 43

3.4.1 Requirements to Information Security 44

3.4.2 Requirements to Communication 45

Technology

3.5 Related Works 47

3.6 Telemedicine Assessment 51

3.7 Summary 53

IV METHODOLOGY

4.1 Introduction 55

4.2 Programming Languages and Tools Used in 63

Project Development

4.2.1 Visual Basic 6 (VB6) 63

4.2.2 SoftWIRE Technology 64

4.2.3 Active Server Pages 64

4.2.4 Structured Query Language (Sequel or 66

SQL)

4.2.5 MS Access 97 66

4.2.6 ActiveX Technology 67

4.3 Data Acquisition from Patient Monitor Unit 69

4.3.1 BSM 8800 RS232C Cable 69

4.3.2 RS232C Interface Protocol for Patient 69

Monitoring System

4.3.3 Visual Basic Communication Tool 70

4.3.4 ECG Waveform Sequential Data 73

Acquisition

4.3.5 Other Vital Signs Data Acquisition 76

4.3.6 Non-Invasive Blood Pressure Data 78

Acquisition

4.4 Patient Database Development 78

4.4.1 Introduction 78

4.4.2 Patient Database Fields Determination 79

4.4.3 Unnormalized Form 80

4.4.4 First Normal Form 81

4.4.5 Second Normal Form 82

4.4.6 Third Normal Form 82

4.4.7 Data Dictionary 83

4.5 Web Pages Development 84

4.5.1 Basic Interface Design 84

4.5.2 Coding With ASP 84

4.5.3 Creating an ActiveX Control for ECG 84

Graph

4.5.4 Data Extraction of the Vital Signs 86

4.5.5 Testing the Program and Web Pages 89

4.6 Project Specification Summary 89

4.7 Conclusion 91

V RESULT ANALYSIS AND DISCUSSIONS

5.1 Introduction 92

5.2 VB Communication Tool Results 92

5.3 Web-based Interface System Screen Captures 94

5.4 MS Access Database 115

5.5 Configuring nS5 115

5.6 Validation of the ECG Graph Control 116

5.6.1 Validation Using Simulated ECG 116

Signals in Non-noisy Environment

5.6.2 Validation Using Simulated ECG 123

Signals in Noisy Environment

5.6.3 Simulated ECG Signals Analysis 130

Results

5.6.4 Validation Using Real Patient ECG 137

Signals

5.6.5 Real Patient ECG Signals Analysis 142

Results

5.7 Other Vital Signs Validation 144

5.8 Conclusion 146

VI CONCLUSION AND FUTURE DEVELOPMENT

6.1 Research Summary 147

6.2 Conclusion 148

6.3 Suggestion For Future Development 148

REFERENCES

APPENDIX A-O

150

161-277

LIST OF TABLES

TABLE TITLE PAGE

2.1 Electrode Positions and Connections for Standard ECG 16

Leads

2.2 Difference between Normal and Abnormal Capnogram 20

2.3 Description of Different Phases of A Capnogram 20

2.4 Functions of the Intensive Care Complex 25

3.1 Wireless Connectivity Technologies 33

3.2 Challenges of Creating Critical Care Databases 39

3.3 Reasons for Slow Adoption of New Signal Processing 40

Method

3.4 Measures Taken to Protect Patient Data 44

3.5 Important Aspects in Telemonitoring Applications 48

4.1 Main Components in Access 97 67

4.2 Code to Send and Receive Data Continuously from Patient 71

Monitor

4.3 Coding to Send Request Out from PC 73

4.4 Waveform Information Sequential File Summary 74

4.5 Format Summary of ECG Waveform Sequential Line 74

4.6 Example of Numerical and Alarm Data 77

4.7 Database Normalization Reasons 79

4.8 Unnormalized Form 80

4.9 First Normal Form 81

4.10 Second Normal Form 82

4.11 Third Normal Form 83

4.12 Procedures for Creating an ActiveX Control 86

4.13 Project Specification Summary 89

5.1 Numerical and Alarm Data Output 108

5.2 Network Connection Settings 116

5.3 Comparison Table for Normal Sinus Rhythm 117

5.4 Comparison Table for Asynchronous Waveform 118

5.5 Comparison Table for Second Degree Block 118

5.6 Comparison Table for Left Bundle Branch Block 119

5.7 Comparison Table for Right Bundle Branch Block 120

5.8 Comparison Table for Atrial Flutter 120

5.9 Comparison Table for AV Sequential 121

5.10 Comparison Table for Nodal Rhythm 121

5.11 Comparison Table for Supraventricular Tachycardia 122

5.12 Comparison Table for PVC 24 min 123

5.13 Comparison Table for Normal Sinus Rhythm With Noise 124

5.14 Comparison Table for Asynchronous Waveform With 124

Noise

5.15 Comparison Table for Second Degree Block With Noise 125

5.16 Comparison Table for Left Bundle Branch Block With 126

Noise

5.17 Comparison Table for Right Bundle Branch Block With 127

Noise

5.18 Comparison Table for Atrial Flutter With Noise 127

5.19 Comparison Table for AV Sequential With Noise 128

5.20 Comparison Table for Nodal Rhythm With Noise 128

5.21 Comparison Table for Supraventricular Tachycardia With 129

Noise

5.22 Comparison Table for PVC 24 min With Noise 130

5.23 Comparison Table for Male A 137

5.24 Comparison Table for Male B 138

5.25 Comparison Table for Male C 139

5.26 Comparison Table for Female D 139

5.27 Comparison Table for Female E 140

5.28 Comparison Table for Female F 141

5.29 Testing the Validation of Other Vital Signs Display 144

LIST OF FIGURES

FIGURE ITEM PAGE

1.1 Total Hospital Information System Concept 9

1.2 Integration Concept for Monitoring 8

1.3 Scope of Project 10

1.4 Overall System Architecture of Proposed Monitoring 13

System

2.1 A Typical ECG Waveform 15

2.2 Einthoven's Triangle 17

2.3 Normal Capnogram 20

4.1 Overall System Setup 55

4.2 Aloka SSD-200 Ultrasound System 56

4.3 Stryker Endoscopy Model 688i 57

4.4 Other Equipments That Are Switched On 57

4.5 Flow Chart of Data Acquisition and Display 59

4.6 Patient Database Web Page Development Flow Chart 60

4.7 Web Page Program Flow 61

4.8 Entry Drop Down Menu 62

4.9 Reports List 62

4.10 Tools List 62

4.11 A COM Object 68

4.12 Basic Interface Design 70

4.13 ECG Waveform Sequential Files 75

4.14 B a s i c Web Page Interface Design 85

5.1 VB Communication Tool Interface 93

5.2 Login Interface 94

5.3 New User Registration Interface 95

5.4 Overview of the System Developed 96

5.5 Patient Details Summary Page 97

5.6 Enter Patient Information Page 97

5.7 Deleting a Patient Record 98

5.8 Searching Through Records Using Patient Name 98

5.9 Results of Search Using Patient Name 99

5.10 Searching Through Records Using Patient Code 99

5.11 Results of Search Using Patient Code 100

5.12 Physician Details Entry Form 101

5.13 Physician Summary Page and Search Using Physician 101

Name

5.14 Results of Search Using Physician Name 102

5.15 Results of Search Using Physician Code 103

5.16 List of Patients Registered in the System 103

5.17 Admit New Patient Under Physician's Own Account 104

5.18 Patient Examinations for Physician Sam Mokhtar 105

5.19 Examination Types 106

5.20 Others Examination Type 106

5.21 Examination and Findings Report 107

5.22 Patient ICU Findings and Exams 107

5.23 Search Unreleased Patients According to Date of 109

Admission

5.24 Discharge Patient Interface 109

5.25 Released Patients List 110

5.26 Reports Generated By System 110

5.27 Print Patient List HI

5.28 Patient Code List Report 111

5.29 Daily Admission List According to Date 112

5.30 Daily Admission Report 1 1 2

5.31 List of Released Patients According to Date 113 i

5.32 Released Patients Report 113

5.33 Useful Links to Other medical Websites 114

5.34 About the System 1 1 4

5.35 MS Access 97 Database Tables 115

LIST OF ABBREVIATIONS

ADO ActiveX Data Object

ASCII American Standard Code for Information Interchange

ASF Active Server Pages

AV Atrioventricular

CCS Critical Care System

CCU Coronary Care Unit

CIS Clinical Information System

COM Component Object Model

CPR Computer Patient Record

CTI Computer Telephone Integrated

DCOM Distributed COM

DICOM Digital Imaging and Communications in Medicinc

DSL Digital Subscriber Line

ECG Electrocardiograph

EEG Electroencephalograph

EHR Electronic Health Record

EMG Electromyograph

EMR Electronic Medical Record

ETCO2 or PETCO2 - End Tidal Carbon Dioxide

GUI Graphical User Interface

HIS Hospital Information System

HL7 Health Level 7

HR Heart Rate

IBP Invasive Blood Pressure

ICT Information and Communications Technology

ICU Intensive Care Unit

ns Internet Information Services

IOM - Institute of Medicine

ISDN - Integrated Services Digital Network

IT - Information Technology

JScript - Java Script

Lab VIEW - Laboratory Virtual Instrumentation Engineering

LAN - Local Area Network

LIS - Laboratory Information System

NIBP - Non-Invasive Blood Pressure

PaCC>2 - Partial Pressure of Carbon Dioxide

PACS - Picture Archiving and Communication System

PC - Personal Computer

PDA - Personal Digital Assistant

PICIS - Patient Integrated Clinical Information System

PIS - Pharmacy Information System

PM - Patient Monitor

PVC - Premature Ventricular Contraction

PWS - Personal Web Server

RIS - Radiology Information System

RR - Respiration Rate

RW - Reconstructed Waveform

SA - Sino-atrial

Sa(>2 or - Oxygen Saturation

Sp02

SC - Strip Chart

TEMP - Temperature

USB - Universal Serial Bus

VB - Visual Basic

VI - Virtual Instruments

VPC - Ventricular Premature Contraction

INF - First Normal Form

2NF - Second Normal Form

3NF - Third Normal Form

LIST OF APPENDICES

APPENDIX ITEM

A An Email Feedback from Dr. Poh Yih Jia

B An Email Feedback from Dr. Yek Kiung Wei

C A Testimony from Dr. Zulkifli bin Taat

D RS232C

E Communication Method

F RS232C Operating Mode

G Numerical Data and Waveform Communication Protocol

H ECG Output Voltage Conversion Table

I Web Page Data Elements and Data Dictionary

J Program Breakdown of Vital Signs Display and ECG

Waveform

K Internet Information Services (IIS5) Setup Procedures

L Software Compatibility

M Vital Signs Information

N Results and Charts

O Our Heart

CHAPTER I

INTRODUCTION

1.1 Background

In the Intensive Care Unit (ICU) or Coronary Care Unit (CCU) and other

critical care settings, patients' physiological state needs to be monitored at all times

but medical staff do not have the human resources and technical capabilities to

perform this task continuously. Ever since the technology of monitoring astronauts'

vital signs in space was transferred to the bedside in the 1960s, patient monitoring

systems have become an essential part of critical care [ 1 ]. Today, these systems can

gather multiple physiological signals simultaneously and derive clinically important

parameters. Many monitoring systems are geared towards remote monitoring of

patients' physiological signals.

Although the amount of information patient monitoring systems provide to

medical practitioners is more than ever before and still improving, the usability and

usefulness of the information is less than desirable. The raw data contains

measurement errors and noise from biosensors. Corrections for these errors and

elimination of noise have to be done for better accuracy of the signals and data

acquired. Data integration and multi-parameter data analysis might be able to extract

useful information from the imperfect raw data, but the state-of-the-art monitoring

systems carried out limited data integration and analysis for effective decision

support. Therefore, many manufacturers are improving their products constantly,

hoping to give more satisfaction and functionality to the practitioners.

One symptom of this lack of data integration and analysis is the lack of

electrocardiograph (ECG) signal analysis. Patient monitors located at the patients'

bedside are able to monitor their ECG signals. However, physicians are unable to

determine the voltage levels of the P, Q, R, S, and T points of the ECG without the

waveform printouts. The same problem also arises for the R-R intervals.

In order to solve these, researchers have been creating web-enabled software

to allow the analysis of the ECG waveform and the peak detection features. The

ability to monitor the patient remotely is an added value for the physicians so that

they do not have to be always on site whenever they want to know their patients'

conditions.

Other than wired applications using landlines, researchers from other parts of

the world are also looking into wireless and mobile applications for remote

monitoring systems. There is little doubt that mobile computing can be a powerful

tool to reengineer business processes. The benefits of such reengineering include

reduced paper handling, reduced travel, improved data accuracy and timeliness, and

reduced need for large central office facilities. Nevertheless, one particularly

difficult issue for wireless communications is security. For instance, some wireless

technologies are not suitable for applications in which sensitive client information is

exchanged between a central database and a remote device because the data signal

can be intercepted [2]. Wireless communication is often ruled out due to cost or

simply not feasible. In some cases, mobile computing must rely on replication and

synchronization of data over landlines. Therefore, it is important to balance the

initial and ongoing costs of implementing these technologies, including training and

support, against the potential benefits of time and monetary savings.

Before proceeding further into the discussion of the research, section 1.2 will

first define the terms of web-based interface system for better understanding the rest

of the discussion in this thesis.