J Med Syst (2013) 37:9978

DOI 10.1007/s10916-013-9978-8

ORIGINAL PAPER

A Cloud System for Mobile Medical Services of Traditional

Chinese Medicine
Nian-Ze Hu & Chia-Ying Lee & Mark C. Hou &
Ying-Ling Chen

Received: 1 March 2013 / Accepted: 28 August 2013 / Published online: 1 October 2013
# Springer Science+Business Media New York 2013

Abstract Many medical centers in Taiwan have started to

provide Traditional Chinese Medicine (TCM) services for
hospitalized patients. Due to the complexity of TCM modality
and the increasing need for providing TCM services for patients in different wards at distantly separate locations within
the hospital, it is getting difficult to manage the situation in the
traditional way. A computerized system with mobile ability
can therefore provide a practical solution to the challenge
presented. The study tries to develop a cloud system equipped
with mobile devices to integrate electronic medical records,
facilitate communication between medical workers, and improve the quality of TCM services for the hospitalized patients
in a medical center. The system developed in the study includes mobile devices carrying Android operation system and
a PC as a cloud server. All the devices use the same TCM
management system developed by the study. A website of
database is set up for information sharing. The cloud system
allows users to access and update patients medical information, which is of great help to medical workers for verifying
patients identification and giving proper treatments to patients. The information then can be wirelessly transmitted
Nian-Ze Hu and Chia-Ying Lee contributed equally to this study and
share first authorship.
N.<Z. Hu
Department Of Information Management,
National Formosa University, No.64, Wunhua Rd.,
Huwei Township, Yunlin County 632, Taiwan
C.<Y. Lee : M. C. Hou (*) : Y.<L. Chen
Department of Chinese Medicine, Changhua Christian Hospital,
No 135, Nanxiao St., Changhua City, Changhua county 500, Taiwan
e-mail: dr.markhou@gmail.com
Y.<L. Chen
Graduate Institute of Education,
National Changhua University of Education, No.1, Jin-De Road,
Changhua City, Changhua county 500, Taiwan

between medical personnel through the cloud system. Several

quantitative and qualitative evaluation indexes are developed
to measure the effectiveness of the cloud system on the quality
of the TCM service. The cloud system is tested and verified
based on a sample of hospitalized patients receiving the acupuncture treatment at the Lukang Branch of Changhua Christian Hospital (CCH) in Taiwan. The result shows a great
improvement in operating efficiency of the TCM service in
that a significant saving in labor time can be attributable to the
cloud system. In addition, the cloud system makes it easy to
confirm patients identity through taking a picture of the
patient upon receiving any medical treatment. The result also
shows that the cloud system achieves significant improvement
in the acupuncture treatment. All the acupuncture needles now
can be removed at the time they are expected to be removed.
Furthermore, through the cloud system, medical workers can
access and update patients medical information on-site,
which provides a means of effective communication between
medical workers. These functions allow us to make the most
use of the portability feature of the acupuncture service. The
result shows that the contribution made by the cloud system to
the TCM service is multi-dimensional: cost-effective,
environment-protective, performance-enhancing etc. Developing and implementing such a cloud system for the TCM
service in Taiwan symbolizes a pioneering effort. We believe
that the work we have done here can serve as a stepping-stone
toward advancing the TCM service quality in the future.
Keywords A cloud system . Traditional Chinese Medicine .
Mobile devices . Electronic medical records

Background
Recently many medical centers in Taiwan have started to
provide services of Traditional Chinese Medicine (TCM) for

9978, Page 2 of 13

hospitalized patients [1]. Doctors of TCM have provided

diverse TCM treatments such as acupuncture, moxibustion,
and herbal remedies. Among these services, acupuncture has
long been attracting strong attention from the public. The
popularity comes not only from its amazing curing power
but also from its portability. Unlike other Western medical
services such as X-rays and gastrocopy for which patients
must be gathered to a designated place for these medical
examinations, acupuncture treatments can be given right at
the place where patients are hospitalized. In particular, this onsite treatment feature is of vital importance to patients who are
not able to move around by their own, e.g., elderly nursing
home patients and physiotherapy patients. The increasing
demand for TCM services from patients in various wards
scattering around the hospital, along with the complexity of
TCM modality, has made it harder to manage the situation
manually without making any careless mistakes. Suchlike
negligence sometimes may be health-threatening for patients.
The traditional electronic anamnesis system along with the
paper-based recording system has become insufficient to assure high-quality TCM services. Under the traditional system,
health care workers need to jot down information on their
patients and then input what they have gathered to the electronic anamnesis system. Such inextricable and repetitive
work tends to not only make the records fallible due to human
error but also expend excessive labor resources that otherwise
can be saved.
Under the current TCM practice in Taiwan, very few TCM
departments have wards exclusive to their hospitalized patients [2]. Consequently, hospitalized TCM patients are most
likely to be admitted to whichever ward has free beds. Due to
factors such as the scattering of hospitalized TCM patients, the
nature of the TCM medical service, and the limited number of
medical staff, doctors and nurses have to go around to different wards so that they may not cooperatively provide services
to the same patient at the same time. For example, doctors first
carry out the acupuncture treatment and nurses then need to
remove the needles in patients after a certain period of time.
The traditional pen-paper-electronic anamnesis system does
not allow these medical staff to share patients medical service
records in a timely manner, which may further cause a waste
of time due to repeated interrogation and enquiry. This also
demonstrates that integrating patients medical information
from various sources and facilitating the exchange of the
gathered information become extremely important.
Even if TCM departments can have their own wards clustering together in a designated area, the traditional pen-paperelectronic anamnesis system still cannot do the job. There has
been a rising trend toward information digitization for medical
institutions [3]. The TCM is thus no exception. Furthermore,
electronic medical records not only can provide instant access
to and update on client information but also can expedite the
exchange of medical image information between hospitals [4].

J Med Syst (2013) 37:9978

For example, a cloud-based emergency health care information service system has been used in India to provide on-site
retrieval of patients past medical records [5]. Following the
global trend, a number of hospitals in Taiwan have started to
build cloud computing electronic health systems for their
western medicine services. In addition, a real-time mobile
nursing information system has also been developed for evaluating patients conditions [6]. In contrast, there has had no
similar development for the TCM service. In order to catch up
with the trend and hence provide high-quality TCM services, a
cloud computing system customized for the TCM service is
much needed.
According to the National Institute of Standards and Technology of the USA, Cloud Computing is defined as a
model for enabling convenient, on-demand network access
to a shared group of configurable computing resources (e.g.,
networks, servers, storage, applications, and services) that can
be rapidly provisioned and released with minimal management effort or service provider interaction [7]. In short, the
cloud system for mobile medical services is aimed to apply the
cloud computing method to medical affairs [8]. The cloud
computing system provides a new way to solve problems
with the medical service. Some studies have recently been
conducted regarding how to implement the cloud framework
in medical affairs [8, 9].
A cloud system for mobile medical services is expected to
make it easier for doctors and nurses from wards at different
locations to access real-time medical records of patients [10].
It is intended to bring together information from disparate
sources such as electronic anamnesis records and medication
records, and thus provide ubiquitous access for those who
need the information during a patients hospitalized course.
Integrating patients medical records to assure low-cost, highquality health care service, however, requires cooperation and
coordination [11]. If widespread support from various groups
of the organization is attainable, the cloud system for mobile
medical services can enhance the accuracy and efficiency of
hospital information systems.
This study is to demonstrate how a cloud system with
mobile devices can improve the quality of the TCM service.
In particular, we place an exclusive emphasis on how the
cloud system can help enhance the effectiveness of the acupuncture treatment. The reasons for the choice are three-fold.
First, the acupuncture treatment has long been the archetype of
the TCM service. Second, acupuncture has also been growing
in popularity. There has been an increasing demand for acupuncture as a complement of or adjunct to other medical
therapies for treating diseases such as cancer, stroke, and
chronic diseases. Therefore, assuring patients of high-quality
acupuncture treatments has been given top priority. Third, the
intricacies of the acupuncture treatment can further underline
the need for a cloud system and the contribution the system
can make to the effectiveness of the acupuncture treatment.

J Med Syst (2013) 37:9978

Page 3 of 13, 9978

Materials and methods

Setting
The regular TCM service at the Lukang Branch is currently
offered at three distantly separate places in the hospitals main
building: the physiotherapy center on the first floor, the outpatient clinic on the second floor, and the nursing center on the
eleventh floor. During a 3-h outpatient clinic session, a physician and a nurse, along with either of an intern or a resident,
are in charge of the TCM service.
Outpatients receive the TCM service in the outpatient clinic
room. Therefore, medical data of these patients can be relatively easily accessed and updated through the computer
system around in the clinic room. However, the situation gets
a bit complicated when doctors give the TCM (particularly,
acupuncture) service to patients at the physiotherapy and the
nursing centers. Doctors must visit these two centers to provide the acupuncture service. Before making such a visit,
doctors need to review the patients medical records, write
down key information, and bring the written note with them.
They then need to jot down their diagnoses and treatments on
the patients. Finally, they bring these new medical notes back
to their clinic office (or to the nearest laptops and PCs with
access to the anamnesis system) and key in the medical notes.
Therefore, a bit more efforts are needed for providing the
acupuncture service to patients outside the outpatient clinic
room.
Normally, breaks are prearranged during the 3-h course of
the outpatient clinic service so that the TCM physician and the
resident are able to visit the physiotherapy and the nursing
centers, and give TCM treatments to their patients during
these breaks. In addition to the normally scheduled visits,
there may be unplanned visits to the physiotherapy and the
nursing centers for providing the TCM service to late-arrival
patients or new patients. This would cause an even hectic
schedule for the medical staff. Furthermore, the travel between
the physiotherapy center on the first floor and the outpatient
clinic room on the second floor takes the doctors some additional time.
Table 1 reports summary statistics of the average number of
patients, the treatment time per patient, the travel time per
visit, and the data processing time across the three places
where the TCM service is provided during the 3-h session.
Table 1 Estimates of time spent
in the acupuncture treatment
at various locations

Details are described below. The TCM medical staff start the
3-h service session in the outpatient clinic. The physician
conducts a routine inquiry on the health condition of the
patient and makes a comprehensive diagnosis. At the same
time, the physician or the resident writes down the diagnosis
result and gives the acupuncture treatment to the patient when
necessary. When an acupuncture treatment is given, any of the
physician, the resident, and the nurse need hand-write down
details of the acupuncture treatment including the number and
the location of the acupuncture needles that are inserted into
the skin. In general, the nurse is responsible for removing the
needles based on the hand-written records. These written
notes are time-consuming, which, coupled with the large total
number of patients the physician needs to treat during the 3-h
session, may lead to a situation where the acupuncture treatment is done but details of the treatment have not been jotted
down. Furthermore, under a time constraint, doctors sometimes cannot record all the details of the acupuncture treatment. Under such circumstances, details of the acupuncture
treatment may be mis-communicated between health care
workers, and the nurse with no complete guidance from the
physician can only remove those needles that can be spotted.
There is then always risk that some needles are inadvertently
left un-removed. In certain cases, this may endanger the
patients health.
The physician, the resident, and the nurse need also visit
the nursing room on the eighth floor and the physiotherapy
center on the first floor during the 3-h session. Only some of
the patients receiving physiotherapy treatments and/or nursing
services need the TCM service, in particular the acupuncture
treatment. Most of these TCM patients, mainly previously
referred to the TCM department by non-TCM doctors, may
receive the Western Medicine treatment and the TCM treatment at the same time. Mostly, the physician gives a dynamic
acupuncture treatment to these patients, under which patients
can still move around as they like to. This is in contrast to the
usual acupuncture treatment, under which patients need to
keep still.
Like physiotherapy patients, most nursing patients are repeat patients but first-time patients emerge occasionally. Furthermore, some of the physiotherapy patients and most of the
nursing patients here are not able to move on their own so that
on-site diagnoses and treatments are necessary. These on-site
services emphasize the need for a more effective system that

Locations

Acupuncture
treatment time
per patient

Additional
data-processing
time in a 3-h session

Travel time
per visit

The average
total number
of patients

Physiotherapy center
Outpatient clinic
Nursing center

10~20 min
10~20 min
10~20 min

10
None
24

3 min
None
5 min

5 patients
8 patients
12 patients

9978, Page 4 of 13

can improve communication of medical information between

members of the medical staff.
The cloud system for mobile TCM service
The proposed TCM cloud system is composed of four medical
databases: a database of patients identification data (e.g.,
personal ID number, hospital ID number, personal photos and
other background information), a database of patients TCM
medical records that is linked to the database of the patients
western-medicine medical records, a database of laboratory test
results, and a database of acupuncture points. Among these
four databases, the acupoint database is of particular interest.
The acupoint database serves as a supporting device for providing doctors with helpful acupuncture tips. It is well known
in the traditional Chinese medicine that energy flows through
regular channels to different acupoints. Certain networks of
regular channels and particular sets of related acupoints must
be taken care of when the acupuncture treatment is given to
patients with a specific disease. The database collects numerous
sets of regular channels and acupuncture points so that doctors
can easily specify the acupoints into which acupuncture needles
will be pushed when they are trying to cure their patients of a
given disease. It also collects a priority list of acupoints, which
can provide useful guides to TCM doctors for performing the
acupuncture service. Besides, doctors can customize the database by storing their personal secret recipes for treating various
kinds of disease. The acupoint database can hence expedite the
acupuncture treatment and at the same time improve the quality
of the acupuncture treatment.
The medical staff can access these databases through various wireless network devices such as personal computers,
laptops, PDA, and Pad. The structure of the system is depicted
in Fig. 1, and the equipment architecture is showed in Fig. 2.
The cloud system integrates mobile app with several back-end
servers. In order to build up a SaaS-like infrastructure, our
database server and application server are virtually hosted in
one standalone server. All data can be accessed through web
services provided by an application server while the data
transmission process is secured against outside parties. Furthermore, the mobile app is designed by HTML5 and jQuery
techniques so that it can be executed on any devices such as
iOS, Android, etc.
System design and deployment
The proposed cloud system has three tiers: the back-end tier,
the application tier and the client tier. Cloud database servers
are located in the back-end tier, which sets up the userauthentication and policy-authorization mechanisms for all
queries. The application tier hosts the web services that can
be invoked by clients to retrieve the intended records from
cloud database servers. Finally, there are two types of clients

J Med Syst (2013) 37:9978

in the client tier: mobile devices and analytical clients. Data

stored in the cloud database server can be accessed via mobile
devices. However, when further analysis, such as statistical
analyses and summary reports, on the retrieved data is needed,
analytical clients must play the role in doing the job.
The system flow
The mobile system The activities involved in the mobile system are depicted in Fig. 3. It focuses mainly on how to enhance
the quality of the TCM acupuncture service. First, through the
mobile system, doctors can review a patients anamnesis and
input the diagnosis results. Based on these records, doctors
decide whether the patient needs the acupuncture treatment.
Second, when the doctor decides to give the patient the acupuncture treatment, she/he can use this database to get helpful
tips for performing the acupuncture treatment. Through the
mobile system, doctors can record the details of the treatment
including the acupuncture points, the number of needles pushed
into the patients skin, and the starting time and the time span of
the treatment for even every acupuncture needle. When the
treatment is done, the system will then warn the person in
charge (e.g., the nurse) to remove the needles and require the
person to confirm that all the acupuncture needles are removed.
Since the time each acupunctural needle must stay stuck into
the skin may vary even in a specific acupunctural treatment, the
cloud system enables the medical staff to remove each needle
precisely at the time when it is needed to be removed. This will
ensure not only that all the needles can be punctually handled
but also that medical negligence can be greatly reduced, significantly enhancing the quality of the treatment. Finally, doctors
can write prescriptions for their patients on-site. Complete
records can be transmitted back to the TCM cloud database
through automatically synchronized mechanisms.
The back-end system Although the back-end system cannot
perform on-site medical services in relation to the mobile
system, it is in fact indispensable to the cloud system of the
TCM service. The back-end system still has its competitive
edge in the cloud system. The system is established through
web interfaces so that users can easily retrieve, manipulate, and
store data via personal computers and laptops. In addition, more
than what the mobile system can do, the back-end system is
capable of doing analytical work through its links with statistical tools. To conserve space, we here present only two types of
the activity flow based on the back-end system. Figure 4 depicts
how the back-end system manages patients medical records.
Figure 5 shows how the acupoint database is maintained.
System structure
The mobile system The structure of the mobile system is
shown in Fig. 6. The system is structured so that it can perform

J Med Syst (2013) 37:9978

Page 5 of 13, 9978

Fig. 1 The cloud architecture

diagram

Cloud System Diagram

Patients medical
records

Personal photos
and medical
imaging

Traditional
Chinese Fourdiagnosis records

Laboratory data

PC
PDA
Pad

three main functions. The first function is to assist the medical

staff in making on-site diagnosis and giving proper on-site
(acupuncture) treatments to patients. The function is of primary importance since portability is a characteristic feature of
acupuncture. We view this function as the most important
contribution our cloud system makes to the TCM service.
The mobile system is also structured to have the function of
calculating Barthel index, which is intended to measure the
health status of a stroke patient. The reason for incorporating
Fig. 2 The equipment
architecture diagram

Laptop

such a function into the mobile system is that acupuncture has

been widely used to cure the disabled. Since these patients are
usually unable to move around by their own, on-site medical
services are especially needed. This also explains why the
TCM doctor in charge of a 3-h outpatient clinic needs to give
on-site acupuncture treatments to patients in the physiotherapy
center and the nursing room, where most of the disabled
patients are hospitalized. An in-time Barthel index measure
becomes important for doctors to evaluate the effectiveness of

Equipment Architecture
Diagram
Mobile Devices
Android3.1 or later
1GB RAM
32GB Storage
Wifi network

Cloud Database Servers

Application Servers

IBM x3650Server
32GB RAM
300GB HD x5 (Raid5)
Windows 2008 Server
SQL Server 2008

IBM x3650Server
16GB RAM
300GB HD x3 (Raid5)
Windows 2008 Server
SQL Server 2008

Analytical Clients
Intel i7 PC
4GB RAM
500GB HD
Windows7 Professional

9978, Page 6 of 13
Fig. 3 The activity diagram of
mobile operations

J Med Syst (2013) 37:9978

Start
review the patients'
medical records

enter four-diagnosis
results
need an acupuncture
treatment?

record acupuncture
places & numbers
time is up?

perform regular task

notify to remove
needles

notify to remove
needles

write prescriptions

finish the treatment

End
the acupuncture treatment on the stroke patient. The third
function provided by the mobile system is data synchronization, which allows members of the medical staff to share the
most current medical data.
The back-end system The back-end is structured mainly to
maintain data of the TCM service (Fig. 7). It however also
provides a link with the database of patients western medical
records so that doctors can review and retrieve their patients
western medical records when necessary. With regard to the
TCM data maintenance function of the back-end system,
doctors can review on Web browsers patients medical records
including Four-diagnosis results, prescriptions written to any
specific patient, acupuncture treatments given to any specific
patient. The back-end system also provides a specialist

knowledge base to help the TCM medical staff improve the

quality of the TCM service. This is done through the following two mechanisms. The back-end system first assembles
various types of acupuncture-related data such as acupoint
layouts, regular channel layouts, and acupoint priority lists
so that members of the TCM medical staff can make easy
reference when they need to. The system then allows users to
define useful configurations such as acupoint sets well-suited
for particular acupuncture treatments, regular channel sets for
particular purposes, and prescription sets for particular diseases. The medical staff can also create their own configurations based on their personal experience and knowledge.
These helpful tips not only save doctors time in giving their
patients the acupuncture treatment but also help doctors maximize the power of the acupuncture.

J Med Syst (2013) 37:9978

Page 7 of 13, 9978

Start

while others are only qualitative in nature. Nevertheless, we

believe that the proposed measures as a whole can assure a
meaningful analysis for the efficiency and capability of the
mobile medical service supported by the cloud system.
Retrieve histrical
records

Input changes in
medical records

Evaluation indexes
1. Time spent in preparatory work for acupuncture (TPA) &
Time needed for keeping acupuncture records (TAR)

Make modifications

Confirm modifications

End

Fig. 4 An activity diagram of the back-end system (a)

An application of cloud computing to the TCM anamnesis

system
The application of cloud computing
We now test and verify the cloud system based on a sample of
hospitalized patients receiving the acupuncture treatment at
the Lukang Branch of Changhua Christian Hospital (CCH) in
Taiwan. We propose several measures to evaluate the effectiveness of the cloud system. Some measures are quantitative

Before the implementation of the cloud system, health

care workers need write down on paper how many needles
are used and inserted into which acupoints. Therefore, a
large volume of formatted paper is needed for the daily
routine. It costs the hospital to buy, prepare, and store the
paper. Extra time is hence needed to get things done under
the traditional pen-paper-electronic anamnesis system. This
means not only a waste of time and money but also a
negative environmental impact. Furthermore, the medical
staff need take notes on what have been done in the
acupuncture treatment. These written notes not only are a
communication means between members of the medical
staff involved in the treatment but also are what to be
added to the medical records of the patient.
After the implementation of the cloud system, no regular
forms need be filled out by hand. All we need to have is a
tablet computer through which the cloud system can be invoked. Anything involved in the acupuncture treatment now
can be handled through the acupuncture record system built
into the tablet computer.
Start

Enter changes in
acupoint

Edit acupoint
layout

Update acupoint set

Edit acupoint
set

Confirm
modifications

Confirm
modifications

New regular channel

sets

Edit regular
channel sets

Edit acupoint
set priority

Confirm
modifications

End

Fig. 5 An activity diagram of the back-end system (b)

New acupoint set

priority

Confirm
modifications

9978, Page 8 of 13

J Med Syst (2013) 37:9978

Fig. 6 The structure of the

mobile system

Historical medical
records

Assist in
diagnose/treatment

Four-Diagnosis

Add/Update

Acupuncture

Add/Update

Mobile Devices

Calculate Barthel
Index
Notify to Remove
Needles

Synchronize

The time spent in making preparations for an acupuncture

treatment (TPA) and the time spent in keeping a record of the
acupuncture treatment (TAR) are two indexes that could be
used to evaluate the time efficiency of the cloud system
through making a comparison between the amount of labor
time for an acupuncture treatment with the cloud system and
that without the system.
2. Punctuality of removing the acupuncture needles (PRA)
The acupuncture needles must stay stuck in the patients
body for a period of time to complete the treatment. Under the
old system, an alarm clock can be used to remind the medical
staff to remove the needles for a particular patient. This is,
however, not able to meet the needs of daily acupuncture
services. At a given point in time, there are often several

patients receiving the acupuncture treatment. Furthermore, for

a given patient, not all needles need be removed at the same
time. What makes matters worse is that doctors and nurses
usually work on separate occasions. A mechanism to ease the
way for communications between medical workers involved in
the acupuncture treatment is strongly needed. It is, however, a
serious challenge for the traditional electronic anamnesis system to integrate relevant information from various sources.
Therefore, under the traditional system, it could happen that
the acupuncture needles are not removed on schedule, caused
by negligence due to lack of information integration and poor
communication between the medical staff.
The cloud system for mobile medical services provides
real-time access to information regarding any acupuncture
treatment in progress. The system develops an alarm device
to alert the medical staff to remove the acupuncture needles at

Fig. 7 The structure of the

back-end system

Four Diagnosis records

Western medical
Records

The Backend
System

Review
Patients TCM
Records

Preseciptions
Acupuncture Treatment
Results

Maintain

Acupoints Layouts
Analytical Work

Assemble
Acupuncture
Related Data

Regular Channels

Acupoint Priority
Formulate Helpful
Tips

J Med Syst (2013) 37:9978

the right time. It will assure the patient a high-quality treatment. The punctuality measure under either of the old and
new systems is calculated according to the time lag between
the scheduled time to remove the needles and the time when
the needles are actually removed.
3. Time-saving in data integration after the acupuncture
treatment (TDI)
Under the traditional electronic anamnesis system,
health care workers have to key in data of the acupuncture
treatment after the treatment is completed . It takes health
care workers extra time over the time needed for the treatment. The cloud system for mobile medical services, on the
other hand, can automatically keep and store medical records when it is invoked, and hence perform the data
integration function concurrently. These important functions allow us to read the historical records as well as the
newly generated records through the system. This automatic data storage function of the cloud system represents an
improvement in time-efficiency of the acupuncture treatment. We accordingly denote the amount of time-saving as
TDI.
4. Percentage of un-removed acupuncture needles (RLN)
Leaving acupuncture needles in patients is a significant
dereliction of health care workers duty. It may not only
reduce the effectiveness of the treatment but also threaten
the health and safety of the patients. However, it can still,
though only occasionally, happen due to negligence, which
can be mostly attributable to poor communication between
health care workers, as previously alluded to.
Before the implementation of the cloud system, the acupuncture needles must be removed based on the records put
down on sheets of paper by health care workers during the
early stages of the treatment. If the records are incorrect and/or
if health care workers are not conscientious enough, it can
happen that not all the needles are removed. The cloud system,
in contrast, can remind health care workers about what to do in
a timely manner. This will surely enhance the quality of the
medical service.
5. Accuracy of patient identification (API)
It is well known that correctly confirming a patients identity is the most critical step in not only giving appropriate
treatments to the patient but also ensuring high-quality medical
services. Hospitals are used to checking patient identification
by identifying at least two of the appropriate identifiers (e.g.,
the patients name, and medical record number or personal ID
number) [12]. In Taiwan, everyone is required to have a health
care card with her/his name and photo on. However, children
may not have a personal photo on their health care cards. Also,
it can happen that people do not take their cards with them

Page 9 of 13, 9978

when they visit the hospital. In these cases, additional efforts

are needed to be made to confirm patients identity.
In addition to the traditional patient identifiers, the cloud
system adopts photographic techniques to identify patients. It
thus allows us to confirm a patients identity through matching
three patient identifiers: the patients photograph, the patients
name, and the patients medical record number when the
patient checks in at the reception desk of the hospital. Furthermore, through the camera on the tablet computer, we can
also take a photograph of the patient right before the acupuncture treatment. We can then compare the new picture with
those, if any exist, already stored in the cloud system to make
sure that the treatment is given to the right person. This on-site
photographic confirmation technique enhances the safety of
the patient receiving the medical service. Photographic identification of patients can assure positive patient identification
and improve patients safety by reducing system errors [13].
6. Human resource management (HRM)
The cloud system for mobile medical services not only
saves time but also spares health care force. Before the implementation of the cloud system, we need at least 4 man-tasks to
give an acupuncture treatment to a given patient. One performs the acupuncture, another makes the record, the third
removes the needles, and the last keys in the data of the
acupuncture treatment to the electronic anamnesis system.
With the cloud system in place, we only need two people to
execute the treatment. One performs the acupuncture and
makes the record in passing, and the other removes the needles
when the treatment is done. Human resources management
becomes relatively flexible after the implementation of the
cloud system.
7. Impacts of on-site access of medical information (IAI)
The portability of the acupuncture service in fact generates
an edge in providing on-site medical service. With the help of
the cloud system, the medical staff can access patients medical records and provide proper acupuncture treatments for the
patients. This kind of service is in fact invaluable and its value
is sometimes hard to measure.
In summary, it is hard, if not impossible, to have a comprehensive measure for the effectiveness of the cloud system.
We, nevertheless, believe that the evaluation indexes we propose can complementarily illustrate how sound the cloud
system can be. Furthermore, it is noteworthy that the fact that
quantitative measures can give us the degree of the improvement made by the cloud system in more concrete terms than
qualitative measures does not necessarily imply that quantitative measure are far more important than qualitative measures
in terms evaluating the effectiveness of the cloud system. Our
ultimate goal is to infer from these quantitative and qualitative
indexes the improvement in TCM service quality attributable
to the cloud system.

9978, Page 10 of 13

Result
A field test
To precisely measure the performance of the cloud system, we
carried out a one-month field test prior to the implementation
of the cloud TCM service at the Lukang Branch of the
Changhua Christian Hospital. Two doctors were assigned to
participate in the test. In the first half of the test period, they
were required to use the traditional paper-based recording
system. Total numbers of patients whose medical records were
processed by the two doctors within the first-half-month period were 20 and 22 respectively. The result shows that the two
doctors have similar data-processing skills since they spend
comparable time processing medical data of an individual
patient. During the second half of the test period, the two
doctors were required to process medical data in different
ways. One doctor was asked to handle medical data of 12
patients using the traditional paper-based recording system
while the other doctor handled the same medical data based
on the TCM cloud system. The doctor using the TCM cloud
system worked more slowly than the other in the beginning,
but became much more quickly as time went by. This indicates that the cloud system can have a competitive advantage
in processing medical data. Finally, the two doctors were
asked to handle an identical set of medical data of 20 patients
with the TCM cloud system. The result shows that the cloud
system is friendly enough for doctors to become familiar with
it after only a short period of time.
Performance of the cloud TCM service
For a month period following the implementation of the cloud
system, we record details regarding how the cloud system
impacts on the TCM service. As summarized in Table 2, the
cloud system does a better job than the traditional system from
various perspectives. Under the traditional electronic anamnesis system, TPA and TA are about 2 and 3 min per patient
respectively. This, along with the observation that no less than
20 patients receive the acupuncture treatment during a typical
3-h period, amounts to a saving in working time of more than
40 min per 3 h. It means a 7.40 % (i.e. 40/(1803)) gain in
time efficiency. Furthermore, under the traditional electronic
anamnesis system, TDI is on average 4 min per patient while it
becomes about 3 min under the cloud system. Note that under
the traditional system, data entry takes less time since it is
easier to key in data on a PC than on a mobile device. This
explains why the saving in TDI time is not that significant.
We, nevertheless, believe that the data entry time using a Pad
will be inversely proportional to the conversance of users.
There will be a big potential for time-saving if proficiency
with the cloud system can improve. The saving in labor
time from increased operating efficiency attributable to

J Med Syst (2013) 37:9978

the cloud system frees up some human resources for the

TCM service.
In addition to the great improvement in operating
efficiency shown by the quantitative measures, the qualitative measures further indicate the superiority of the
cloud system. The cloud system makes it easy to confirm
patients identity through taking a picture of the patient
upon receiving any medical treatment. The result also
shows that the cloud system achieves significant improvement in the acupuncture treatment. There are no
longer un-removed needles. Furthermore, all the needles
now can be removed at the time they are expected to be
removed. Furthermore, on-site access of patients medical information provides a means of effective communication between medical workers. These functions allow
us to make the most use of the portability feature of the
acupuncture treatment. This in fact represents a significant enhancement in the quality of the TCM service.

Conclusion
One of the most characteristic and attractive features of
acupuncture is that the acupuncture treatment can be given
right at the place where the patient is. Though this on-site
treatment feature gives acupuncture a tremendous advantage over other therapies, it, along with the complicated
process of the acupuncture treatment, poses a challenge to
medical workers. The study therefore develops a cloud
system to make the most use of the on-ste treatment feature
of acupuncture.
The proposed cloud system not only offers instant access to
patients medical data but also integrates patients new medical information from various sources in a timely manner,
which helps establish an effective communication system for
medical workers involved in a given acupuncture treatment.
Our result shows that the cloud system results in a significant
saving in labor time, increasing the flexibility in managing
human resources of health care. Medical workers now can
have ample time to take care of their patients and to conduct
extensive medical research. The cloud system hence provides
further impetus to improve the quality of the TCM service.
The effective communication mechanism provided by the
cloud system in fact makes other considerable improvements
in the TCM service. It enables doctors to give an on-site
acupuncture treatment to a patient. The system also ensures
that every acupuncture needle can be removed at the scheduled time, improving the effectiveness of the acupuncture
treatment.
In sum, this work has illustrated the benefit of providing
mobile medical services, supported by automated electronic
anamnesis storage and update using Cloud Computing, at
Lukang Branch of Changhua Christian Hospital in Taiwan.

J Med Syst (2013) 37:9978

Page 11 of 13, 9978

Table 2 The as is/to be analysis of the TCM cloud system

Medical steps

As is
Items

To be
Items

Review a patients
medical records

Labor (time) cost:

1. The patients anamneses must be prepared by
HIS in advance. (TPA: 2 min)
2. The doctor reviews the patients medical data
on the computer and writes important information down
on paper. (TAR: 3 min per patient to take notes)

Record diagnosis
and acupuncture
results

Labor (time) cost:

The doctor writes down diagnosis results on paper.
Furthermore, the doctor must record the acupuncture
treatment results manually within her/his memory.
After the treatment is completed, medical workers
must key in the medical data. (TDI: 1 min +1 min
and 10 s per patient+2 min)
The doctor hands over the patients medical records
and memos to another doctor. However, data may
be lost in the process.
Overhead cost:
Numerous sheets of paper are used to record
details of the acupuncture treatment in a typical
day. (100 pieces of paper per day)
Risk: Diagnosis and acupuncture results may not
be completely written down when the doctors
memory does not serve him correctly. Besides,
papers of the medical records tend to get lost.
Lack of information integration and poor
communication between medical workers involved
in the acupuncture treatment make it hard to have
all the needles removed as scheduled. Furthermore,
it could, though very occasionally, happen that some
needles are left behind and they are removed only
when they are found. (Punctuality: not good enough)
(Un-removed needles: possible)
The patients health care card is used to verify her/his
identity. However, children may not have a personal
photo on their health care cards. Also, it can happen
that people do not take their cards with them when
they visit the hospital. These cases call for additional
efforts to confirm patients identity and mistakes may
still, though very occasionally, happen. (API: not perfect)
Four man-tasks are needed to perform the acupuncture,
to write down the records, to remove the needles, and
to key in the medical data. (HRM: 4 man-tasks)
Many extra efforts must be made for giving the
acupuncture treatment to patients outside the
outpatient clinic room. Medical information
of the patient cannot be easily exchanged
between medical workers.
Labor cost:
Patients data must be retrieved from HIS and
copied to destinations for further processing. (1 min)
Computer time cost:
Much time is required to transfer data between
heterogeneous systems. (very time-consuming)

Labor (time) cost:

1. All data can be freely accessed through Pad. The doctor
can retrieve the patients anamneses from Pad on site.
There is no need to make hand-written notes on paper.
(TPA & TAR: 10 s per patient)
Risk: Confidential data may be disclosed, which, however,
can be overcome by adopting an encryption mechanism.
Labor (time) cost:
The doctor need not write down the diagnosis and
acupuncture treatment results. Instead, she/he can
update the patients medical data through on-site
mobile devices. Data synchronization between the pad
and the server is executed automatically. (TDI: 3 min)
Any doctor with an assess code can view the patient
medical records and memos made in the passing of
time. Data are kept in pads seamlessly and safely.
Overhead cost:
No paper is needed for manually recording details
of the acupuncture treatment.
There will be no loss of data. All the data are now
synchronously stored in the server through Pad.

Improve the
acupuncture service

Confirm patients
identity

Improve human
resource
management
Enhance on-site
medical services

Analyze historical
medical records

The result shows that the contribution made by the cloud

system to the TCM service is multi-dimensional: costeffective, environment-protective, performance-enhancing
etc. Developing and implementing such a cloud system for

The cloud system can remind medical workers to

remove the needles when the treatment is done.
It will also make sure that all the needles are removed.
(Punctuality: perfect) (Un-removed needles: none)

The cloud system allows us to take an on-site

picture of the patient upon receiving any medical
treatment, through which the patients identity
can be easily confirmed with no error. (API: perfect)

Only two man-tasks are needed. One perform the acupuncture

treatment and make the records in passing. The other is
responsible for removing the needles. (HRM: 2 man-tasks)
With the cloud system, the medical staff can access
patients medical records and proper in-time and
proper acupuncture treatments for the patients. (IAI: great)

Labor cost:
Patients medical records can be directly transmitted from the
TCM cloud database to designated destinations. (<5 s)
Computer Time cost:
Little time is spent transmitting data since it is now a system
of 1-by-N relations rather than a N-by-N system. (<5 s)

the TCM service in Taiwan symbolizes a pioneering effort.

We believe that the work we have done here can serve as a
stepping-stone toward advancing the TCM service quality in
the future.

9978, Page 12 of 13

Discussion
There are several issues needed to be addressed for wide
application of the TCM cloud system. First, the Wi-Fi penetration rate needs to be raised in the hospitals for which the
cloud system will be established. Although 3G-carried mobile
devices can operate without Wi-Fi, the transferring speed and
the fair cost tend to balance out the great merit. On the other
hand, the cloud system for mobile medical services must work
within a Wi-Fi environment. This in fact has posed a big
problem for many hospitals in Taiwan, and this also has been
the case for many hospitals in regions such as Europe, Asia,
and even North America.
However, with the rapid development of information technology, the Wi-Fi service penetration has been increasing in
recent years. According to a prediction made by a global
telecommunications equipment company, the number of public Wi-Fi Hotspots is set to proliferate, growing from 0.8
million at the end of 2010 to 5.8 million by the end of 2015
[14]. Furthermore, the continued expansion of broadband
services provides a solid foundation for further growth in
Wi-Fi adoption. Thus the problem of low Wi-Fi penetration
rate will be solved very soon.
Second, the medical cloud system we propose is built
under the Android operating system (OS). Therefore, the
mobile device is limited to those compatible with the
Android OS. Although Android is by far the most popular
smart phone OS, iOS also plays an important role in the
tablet and smart phone markets. A key factor in popularizing
the medical cloud system is to make it compatible with
various operating systems, a goal we will pursue in the next
stage.
Consequently, we chose 7-in. tablets as the mobile device.
The most important advantage of a 7-in. tablet is its suitable
size for mobile medical services. Compared with 10-in. tablets
like the iPad, 7-in. tablets are characterized by small but
convenient size. Furthermore, a 7-in. tablet can fit neatly into
the pockets of the white garb, making it easy for medical
workers to bring the tablet with them. Also, the medical staff
now can easily take notes on the wrist. Another important
advantage of the 7-in. tablet is its affordable price. Prices of
7-in. tablets are usually lower than those of 10-in. tablets.
From the perspective of cost-effectiveness, 7-in. tablets are
hence more competitive than 10-in. tablets.
The last concern is the choice of a reliable server. The cloud
system for mobile medical services requires a large amount of
data storage and transformation. The amount of data is continuously increasing. Furthermore, the server of the cloud
system must be able to allow multiple users to access data
files simultaneously. The information system for the medical
service is much complex than that those for other industries. A
server with trustworthy performance and great stability is
necessary to assure a dependable cloud system.

J Med Syst (2013) 37:9978

When the cloud system is applied to mobile medical services,

data privacy and security become extremely important. The
cloud system must be able to guarantee the confidentiality and
integrity of medical data. Many proposals that are presented to
use cloud computing for mobile medical services also address
security concerns in mobile cloud computing [10]. Reinforcing
information security and defending the system from unwanted
intrusions become the essential issues [10]. With the progress of
the cloud system for mobile medical services, innovations in
managing data privacy and security will also be required to complement the demand. The discussion indicates that security updates to protect existing infrastructure are a continuous necessity [15]. Therefore, if we
want the cloud system to have good performance, a procedure
to make sure of security must be built in inside the infrastructure so as to protect data from flowing out [15].
Although mobile devices have limited computational capacity to run secure multimedia signal processing algorithms
in mobile applications [15], it has become an imperative for
the cloud system for mobile medical service. For example,
HTTP basic access authentication, a basic method for authentication, asks users to provide a user name and a password
upon making a request. Besides, the Radio frequency identification (RFID) is often used to identify assets and people in
hospitals [16], and it can be used to check the identification of
patients and medical workers [17]. Although the RFID approach still has some security concerns that are needed to
improve [16], it should be considered in the future version
of the cloud system. An isolation mechanism should be
established to make sure that electronic anamnesis is not
commingled with other cloud databases, thus ensuring data
security, data integrity, and data encryption [15].
At the current stage, the security of our system is not strong
enough to keep the system from being infiltrated. For the
foreseeable future, we will continue to develop several infrastructure devices, including confidentiality of data transfer,
authentication, and authorization [18], to enhance security .
The application of mobile devices to pervasive healthcare
information management has already been acknowledged and
well established [19]. However, mobile devices have not been
introduced for TCM medical services. The study initiates a
cloud system that is particularly suited for mobile TCM medical
services. Although there is still room for improvement on the
proposed cloud system, it in fact lays the groundwork for further
development of a sound cloud system for mobile TCM services.
Acknowledgments This study was supported by a grant from
Changhua Christian Hospital, Changhua, Taiwan (No.:101-CCH-IRP75). The authors would like to express their sincere appreciation to Mr.
Bo Shang Chao and his staff at Department of Information Management,
National Formosa University, for helping fix program codes, and to Dr.
Shu-ching Lee and Dr. Zong-syun Jiang from Department of Chinese
Medicine at Changhua Christian Hospital in Taiwan for assisting with
data collection.

J Med Syst (2013) 37:9978

Authors Note Nian-Ze Hu and Chia-Ying Lee contribute equally to
this work. Nian-Ze Hu is mainly in charge of system development, and
Chia-Ying Lee is responsible for clinical application study.

Page 13 of 13, 9978

10.

Conflict of Interests The authors declare that they have no conflict of

interest.

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