Building a Wireless Telemedicine Network within a

WiMax based Networking Infrastructure

Ivan Chorbev #1, Martin Mihajlov *2
#
Faculty of Electrical Engineering and Information Technology, University "St. Cyril and Methodius"
Karpos 2, PO Box 574, 1000 Skopje, R. of Macedonia
1 [email protected]
*
Faculty of Economics, University "St. Cyril and Methodius"
Krste Misirkov bb, 1000 Skopje, R. of Macedonia
2 [email protected]

Abstract—This paper presents an overview of an telemedicine is especially suitable for areas lacking proper
implementation of a WiMAX based integrated system for e- cable connections or places where installing cable links is
medicine that we propose and implement in the Republic of expensive, difficult, economically unviable or simply
Macedonia. Here we present various telemedicine multimedia impossible. For instance, in cases of natural disasters [4], [13],
services we developed and the QoS related to them. The
problems and challenges for using a public wireless IP network
installing wireless links is the only possible way to establish
for setting up the system are also presented. communication and provide better medical service.
As a result of the fast development of telecommunication
I. INTRODUCTION technologies and growing interest in telemedicine, many
The term telemedicine literally means application of telemedicine applications have been developed and deployed
medicine over distance. This concept is described in various during recent years [1],[2],[3],[4],[5],[7]. Telemedicine has
ways and can be accepted as a universal definition. The World various potential uses such as clinical, educational and
Health Organisation (WHO) describes telemedicine as: administrative. Telemedicine can bring high quality medical
...Practising of medical care by using interactive service to under-served areas. It is an example of how IT can
audiovisual and data communication, including medical care, reduce the cost and increase quality. Experiences [9] show
diagnosis, consultations and medical treatment, as well as that telemedicine provides a solution to various problems such
education and transmission of medical data. as access to care for large segments of the population,
Wireless telemedicine has recently drawn attention from reducing healthcare cost, bring experience and expertise closer
health care providers and recipients, governments, industry, to patients, solve uneven geographic distribution of service
and researchers. Although various ideas have been quality, and improve quality as a result of providing
implemented, the practical realization of telemedicine highly coordinated and continuous care for patients, targeted and
depends on advances in computing and networking highly effective continuous education for providers, and
techniques. In recent decades technological development has highly effective tools for decision support.
largely made the delivery of health services, including Telemedicine is a specific field where different services
medical diagnosis and patient care, possible from a distance. need various, often extremely high levels of reliability and
Telemedicine has become a growing new interdisciplinary robustness. Therefore the applied communication technology
field, which will eventually contribute to improving the must support different QoS guarantees. For example, wireless
quality of health care for everyone. telemedicine/eHealth applications may require transmission of
The low bandwidth or high costs of previous wireless huge volume of non-real-time diagnostic data (e.g., images)
technologies disabled advanced telemedicine services. and real-time video or audio data simultaneously. QoS support
Researchers have been attempting to transmit medical data should be provided in different mobility scenarios (e.g., in a
over wireless or mobile links since the deployment of second mobile ambulance environment as well as in a static in-
generation mobile networks (2G) or Global System for Mobile hospital environment). High-speed wireless transmission with
communication (GSM), which for most applications was QoS support would be required for video and voice
limited to a bandwidth of around 10 kbps. Later 2.5G or communications between injured patients and physicians
General Package Radio Service (GPRS) was used, followed during prehospital service. Several QoS parameters (like
by 3G and now 3.5G High Speed Downlink Packet Access throughput, timeliness, reliability, security, and cost) must be
(HSDPA). Higher bandwidth was achieved by using WiFi taken into account when designing an integrated system for E-
802.11, but with the limitations of very short distances. Medicine.
Recently, the establishment of broadband wireless The rest of the paper is organized as follows: After the
standards like WiMAX (IEEE 802.16) enabled introduction in section 1, a short overview of the work by
implementation of telemedicine functionalities that were other authors is presented in section 2. A short overview of the
previously only possible with cable links. Wireless WiMax IEEE 802.16 standard is given in section 3, followed
by a description of the network infrastructure we used in the • Unsolicited Grant Service (UGS) for VoIP applications
project, in section 4. Section 5 gives our implementation of with constant bit rates;
the QoS requirements in the telemedicine system we are • Real Time Polling Service (rtPS) for video applications
developing. An overview of the developed multimedia with variable bit rates;
services in our system is given in section 6, followed by the • Extended rtPS (ertPS), for VoIP applications with
concluding remarks in section 7. silence suppression features;
• Non Real Time Polling Service (nrtPS) for file transfer
II. RECENT WORK applications;
The authors in [15] present the architecture and • Best Effort (BE) service for web browsing applications.
implementation of telemedicine via internet for heart sounds In the IEEE 802.16 QoS model, each packet contains a set
and hearing screening diagnosis. Web based application are of QoS parameters, for instance: traffic priority, maximum
used as a medium for interaction between patients and sustained traffic rate, maximum traffic burst, minimum
doctors. Several wireless telemedicine multimedia services are reserved traffic rate, minimum tolerable traffic rate, tolerated
presented in [2], [5], [6], [7], [9], [16] and [19]. jitter range, maximum delay, vendor-specific QoS parameters,
When commercial IP based networks are used for and request/transmission policy.
telemedicine systems, it is essential to provide sufficient QoS The functional entities defined in the standard are the
required by real time traffic such as interactive video and Subscriber Station (SS), or Mobile Station (MS) in IEEE
audio applications. The authors in [14] analyse the quality of 802.16e, and the Base Station (BS). The BS is responsible for
service requirements for a typical rural telemedicine the centralized QoS scheduling inside its cell based on QoS
applications and then propose proper scheduling, traffic parameters configured by the management system and the
engineering and fast-rerouting as mechanisms that can active bandwidth requests received from the SS. The SS or
compensate for IP’s best effort debilities. A QoS framework MS must identify a BS, acquire physical synchronization,
for telemedicine applications given in [17] and [18]. obtain MAC parameters, and attach to the network. In IEEE
802.16, connections are identified by a Connection Identifier
III. THE IEEE 802.16 STANDARD AND ITS QOS (CID) and not by the MAC address of the host as in other
Due to specific circumstances in the Republic of IEEE 802 standards (IEEE 802.11 for example). The SS MAC
Macedonia, we used a WiMAX network as basis for our address is only used in initial authentication.
telemedicine services. WiMAX is a telecommunications The mobility support introduced in the IEEE 802.16e
technology aimed at providing broadband wireless data standard includes power-saving specifications and handover
connectivity over long distances. It is based on the IEEE procedures. With respect to power-saving, two modes of
802.16 standard. The high bandwidth and increased reach of operation are specified: Sleep and Idle. The Idle mode is more
WiMAX make it suitable for providing a wireless alternative power conserving than the Sleep mode, as the MS can turn off
to cable and DSL for last mile broadband access. WiMAX can completely and become periodically available for downlink
provide broadband wireless access (BWA) up to 30 miles (50 broadcast messages without being registered with any BS.
km) for fixed stations, and 3 - 10 miles (5 - 15 km) for mobile With respect to mobility, although different handover types
stations. In contrast, the WiFi/802.11 wireless local area are supported in the standard, such as Hard Handover (HHO),
network standard is limited in most cases to only 100 - 300 Fast Base Station Switching (FBSS) and Macro Diversity
feet (30 - 100m). Handover (MDHO), only HHO is mandated to be supported
The ETSI HiperMAN [12] is the European version of IEEE by all equipment. With HHOs, transfer interruptions are
802.16 addressing spectrum access in ranges under 11 GHz. possible when a mobile node switches from one BS to
There is a second European standard emerging called ETSI another. The handover decision can be taken by the BS, MS or
HIPERACCESS that will define (mostly licensed uses) above by another network entity. The MS gets knowledge of existing
11 GHz (approximately). The IEEE 802.16 standard covers neighbours via management messages transmitted periodically
spectrum ranges up to about 66 GHz inclusively by the BSs. Using this information the MS can perform scan
When building telemedicine functionalities, the quality of and association procedures. Once the handover decision has
service (QoS) of the communication is essential, especially in been made, the MS begins the synchronization process with
critical services like life video streaming of surgeries or other the target BS.
diagnostic signals, teleconferences. The IEEE 802.16 standard
includes features like integrated QoS and mobility support. IV. WIRELESS INFRASTRUCTURE
The IEEE 802.16-2004 (also known as IEEE 802.16d) [10] There are several state-wide backbone networks operated
and IEEE 802.16e are the most popular versions of the by various data communication providers in the Republic of
standard. The standards define several functionalities, such as: Macedonia. In order to implement our telemedicine system we
operation in line of sight (LOS) and in non line of sight used the backbone network of a fast growing privately owned
(NLOS) conditions, integrated support for different data communication provider. The backbone network consists
scheduling services, mobility, and extended coverage. The of some fiber optic connections in the city limits of Skopje
scheduling services supported include: and mostly 802.16 (WiMAX) base stations throughout the
country. The optic fiber connections are used for provision of
fast bandwidth services where possible. The WiMAX
antennas are used for connecting hospitals where the optic
fiber has not reached yet and 802.11 hotspots are used for
wireless devices (PDAs, notebook PCs etc.) Other providers
operate completely fiber optical backbone networks
throughout the country, but due to lower costs of WiMAX
based systems and other advantages, we decided to use the
network in question.
Within the city limits of the capital Skopje there is a
functional fiber optic Metro Ethernet network. Hospitals in the
city are (or will be) connected to the network. The fiber
optical connection enables fast and robust connectivity for
provision of advanced telemedicine services like high quality
video streaming of surgical procedures, medical visualization
etc. Even when the fiber optical lines are used for
communication, the WiMAX wireless lines could be used for
backup in case of disrupted cable communication. While
Fig. 2. Distribution of hospitals in towns across the Republic of Macedonia
cables can be physically cut, the WiMAX connections are
stable even in severe weather conditions. The WiMAX infrastructure is developed mostly with
A wireless backbone network is established throughout the products from Alvarion, and especially the BreezeMax
country, and hospitals in different cities are (or will be) products line. The network also includes devices from Cisco
connected to the network. Antennas are placed on hills and Alcatel.
overseeing cities, and coverage with the radio signal is good BreezeMAX supports a wide range of network services,
and robust. The backbone network is depicted in Figure 1. including Internet access (via IP or PPPoE tunneling), VPNs
and Voice over IP.
BreezeMAX supports service recognition and multiple
classifiers that can be used for generating various service
profiles for defining various QoS for each service profile.
When using VoIP devices that do not support the DRAP
protocol, the required QoS service can be provided through a
Data (L2) service with a CG QoS that is defined in accordance
with the estimated bandwidth required for the service. The
required bandwidth depends on several parameters, such as
codec type, sample rate and T.38 Fax Relay support.

V. IMPLEMENTED QOS REQUIREMENTS

Our wireless health care network consists of entities linked
via the public WiMAX network. Sharing the network with
other subscribers can have negative impact on the
transmission of medical data. For instance, if the network is
congested, the chances of packet dropping, delay, and
reductions in the bandwidth can increase. Therefore strict QoS
Fig. 1. Scheme of the wireless backbone network in the Republic of requirements had to be implemented for every multimedia
Macedonia
service build into the system.
Within the hospital premises, a process of placement of Wi- Based on the options provided by the used technology we
Fi access points is under way. The wireless connectivity created 5 different service profiles, with various levels of
should be used by both medical personnel and patients. priority. We distributed our multimedia services in the 5
groups according to the estimated priority of each one of
them. The highest priority is given to services with life video
and audio streaming of diagnostic data (tele-consultations).
The lowest priority is given to the common use of the Internet
for browsing medical scientific papers and various online chat
rooms for delayed written consultations. The three middle
levels of priority are given to various services performing
uploads and downloads of multimedia diagnostic material
(images of X-Ray, MRI, Ultra sound and similar content).
Also VoIP conversations are classified in two groups: medical
consultations and common business communication, giving a
higher priority to medical consultations. Separate IP phones
are used for both tasks. The necessary data exchanges for non-
urgent cases are mainly scheduled and performed at night
when the IP traffic is minimal and the probability of causing
congestion is small.
Other concerns about the use of public mobile networks for
health care applications are the security and authentication
issues. This was avoided by using tunnelling mechanisms, i.e.,
establishing VPNs. VPNs have been used traditionally in wire
line networking technologies. Currently, VPN is widely used
over the Internet, allowing reliable, secure remote access to
the users of private networks. In the case of wireless networks,
mobile VPNs (MVPNs) can be used to add extra immunity to
the links.
TABLE I
SOME OF THE TYPICAL DATA RATES REQUIRED BY TELEMEDICINE DEVICES Fig. 3. The web based medical information system in the Institute for
respiratory diseases in children-Kozle
Device Required Data Rate Querying data in the web based MIS is possible using
Digital blood pressure monitor <10 kbps multiple criteria. Data can be searched from other patients
Digital thermometer <10 kbps with similar symptoms in order to learn from other previous
Digital audio stethoscope with ECG <10 kbps experiences. Entire patient history is accessible online, with
Ultrasound 256 kb per image strong regard to privacy issues. While patient identity details
MRI 384 kb per image are available to the physician in charge of the particular case,
Scanned x-ray 1.8 Mb per image
for other medical personnel with lower access privileges, only
medical information is available, without disclosing the
Digital radiography 6 Mb per image
identity of the particular patient.
Mammogram 24 Mb per image A vital part of a telemedicine system is the sharing of
Compressed and full motion video 384 - 1544 kbps knowledge, experience and expertise. The implemented MIS
includes a forum and a virtual chat room where physicians can
The classification of multimedia services in different consult each other. Since the children’s hospital and the
priority levels brought sufficient quality for appropriate tasks. university hospital are connected to the same system,
The scheduling of non urgent communication and processing consultations are possible among physicians from both
freed resources for urgent operations that often emerge in hospitals. The system has an Internet interface toward the
medical systems. The strain on the equipment was more outside world where advices can be gathered or given to
uniformly distributed. physicians anywhere in the world. WiMAX is also used for
Voice over IP (VoIP) services. PSTN telephone bills are
drastically reduced as a result of the use of VoIP for
VI. IMPLEMENTED MULTIMEDIA SERVICES AND FUNCTIONALITIES communication among hospitals.
Implementation of telemedicine services is lengthy and The developed system includes software components
practically a never ending process. At the initial stages two specialized for use by PDA devices. Both patients and staff
hospitals were included in the pilot project: The Institute for can wirelessly access different software modules. Physicians
respiratory diseases in children-Kozle and the University can access patient’s data, results from laboratory analyses,
clinical center in Skopje. Due to the lack of a modern Medical forums and chats, web sites with medical scientific papers.
Information Systems (MIS) in the hospitals, the project had to Patients can access their results from different analyses, make
start from scratch. We developed the initial Web based MIS to appointments, and check the availability of certain physicians.
be used by the staff at the Kozle children’s hospital. Since the We paid great attention to the usability of the user interface in
hospital cannot afford to maintain an IT department, the MIS the PDA applications. Due to the resolution and dimension
is hosted on the Internet Service Provider’s (ISP) servers. limitations, significant effort was made to maximize the
Knowing that connectivity speeds are high enough when using utilization of the given space on the small screens and to
WiMAX, there is no need to host the MIS locally at the enable easy navigation through the user interface. We adopted
hospital. The MIS is developed as a web application that can a policy of gradual increase of details presented on demand,
be accessed by a common Internet browser. The staff at the since scrolling and navigating large texts is unpleasant on a
hospital can browse the MIS, log in using their username and PDA device.
password and access patient’s data. The homepage of the web The system includes a Short Message Service (SMS)
application is presented in Figure 2. gateway that is used for SMS notifications for both physicians
and patients. Current functionalities include confirmation of
appointments for patients, notification for completed in the experiment was SCOM MPEG-2 Digital Video
laboratory analyses, SMS emergency calls for physicians on Encoder/Decoder. The used WiMAX antennas support 2-10
stand-by etc. The system can even notify the patient for the Mbit/s. The particular experiment used 2 Mbit/s, but an
upcoming time for therapy or treatments. acceptable video quality is achieved even with a 512 Kbit/s
Initially telemedicine was defined as provision of medical connection. Another experiment was conducted using a
services at remote locations without direct physical contact personal computer instead of a specialized MPEG coding
between the physician and the patient. Our system device; however a noticeable delay was evident in the video
incorporates modules that enable laboratory results and other stream. The later architecture is applicable for a smaller
analyses to be submitted for review to the specialists. spectrum of services.
Physicians working in smaller towns can access the system The small indoor antennas were also used for video
using their accounts and can submit questions along with telephony experiment. We tested a scenario where an older
supporting materials electronically. Special web application woman suffering from strong pain in the back and almost
software modules are developed for submitting images (MRI, immobilized, had to communicate with her doctor for
X-Ray, CAT scan) from remote hospitals in the country to the consultation. Since transportation of the patient was difficult
specialist working in the capital. Also results from blood and painful, we brought the WiMAX antennas and IP video
analysis are filled in online forms. Specialists review the phones at both locations (the patient’s and doctor’s) and
results and can post their reply to the sender. This system established a video link that they used for consultation. We
enables reduction of transport costs, response times are also used the video phones for establishing sign language
drastically smaller and patients do not have to suffer through communication for patients with impaired hearing. We used
long trips to the specialist. We introduced a system of grading Leadtek IP broadband videophones (BVP8882). They use
each submitted material giving it different priority according H.323 protocol for high performance and good quality video
to the contents and level of urgency demanded by the sender. communication. The quality of the video stream using only
Extremely urgent submissions can even cause the SMS 256 Kbit/s was sufficient for the common sign language to be
gateway to notify the specialist for the incoming request. used and understandable by the communicating parties.
The next step is connecting the Special Hospital for The video signal that we used in most of the testing
Orthopedics and Traumatology "St. Erazmo" in Ohrid, in originated from a digital video camera. Another even more
south-western Macedonia. The hospital already operates one import feature is streaming of digitalized video signals
of the most advanced MIS in the country. One of the system received from analogous endoscopy equipment. We worked
challenges will be integration of the current MIS in Ohrid with on digitalization of an analogous signal from a fluoroscopic
the newly developed in Skopje. However with the use of camera using a Plextor MPEG encoder. The digital output
XML and Web Services, helped by the fast connections of from the encoder was easily streamed. The received live video
WiMAX, initial results are promising. Since the hospital is could be used to consult subspecialists not present at the
situated about 170 km from the capital, Skopje, traveling is location where the exam is performed. Using VoIP and chat
often a problem for patients in critical condition. We already on PDA devices, the specialist could provide feedback and
tested streaming video through the WiMAX connections and guidance to the person performing the exam in the field or in
the next step is to enable experts from Skopje to oversee the remote hospital.
complex surgical operations performed by the surgeons in The implementation of the system consists of three main
Ohrid specializing in traumatology and orthopedics. Similarly, parts: the database, the online web applications and a
students at the University hospital in Skopje will be able to standalone application that performs batch data processing
learn from the live feed from surgeries at the specialized and performs scheduled jobs and maintenance functionalities.
hospital in Ohrid. On the opposite side, experts in the Ohrid Most of the applications are developed in Microsoft .NET
hospital can offer advice to colleagues in Skopje over specific technology, using SQL Server 2005 as a database engine.
interventions performed only in Ohrid. Tested speeds promise However, due to the system’s modularity and the
high quality video. interconnections using platform independent web services,
We performed a video streaming experiment using a certain parts are coded in PHP and hosted on Apache servers
vehicle equipped with a WiMAX antenna and an MPEG using MySQL databases. Increased interaction and faster
coding device. We established a continual video stream that response times for the web applications is achieved with the
could be used to transmit live feed from the patient in the use of AJAX. However, backward compatibility had to be
ambulance to the hospitals. The video link enables specialists taken in consideration due to the various older equipment
to give advice to first aid workers on the scene of an accident, found in different hospitals.
based on real time video feed from the patient’s condition.
Paramedics could be supervised by experienced medical
personnel while performing necessary life support
interventions. Due to current limitations of WiMAX, the
ambulance must not move while being connected online.
However new equipment based on Mobile WiMAX (802.16e-
2005) is expected to overcome this issue. The equipment used
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