EXPERIMENTAL & CLINICAL CARDIOLOGY

Volume 20, Issue 7, 2014

Title: "Moving Toward Data and System Interoperability in Tele-cardiology: Using Pacs Compatible
12-lead Ecg and Structured Reports on the Cloud"

Authors: Jui-Chien Hsieh, Hsiu-Chiung Lo, Fong-Ren Wu and Chung-Chi Yang

How to reference: Moving Toward Data and System Interoperability in Tele-cardiology: Using Pacs
Compatible 12-lead Ecg and Structured Reports on the Cloud/Jui-Chien Hsieh, Hsiu-Chiung Lo,
Fong-Ren Wu and Chung-Chi Yang/Exp Clin Cardiol Vol 20 Issue7 pages 1002-1009 / 2014

Moving Toward Data and System Interoperability in Tele-cardiology: Using Pacs Compatible 12-lea...

Experimental and Clinical Cardiology

Moving toward Data and System Interoperability in

Tele-cardiology: Using PACS Compatible 12-Lead ECG and
Structured Reports on the Cloud
ORIGNAL ARTICIE
Jui-chien Hsieh, Ph.D. 1*, Hsiu-chiung Lo 1, Fong-ren Wu

1,2

, Chung-chi Yang, M.D.3

1. Department of Information Management, Yuan Ze University, 135 Yuan-Tung Road, Chungli, 32003, Taiwan
2. Department of Information, Taoyuan Armed Forces General Hospital, Longtan, 325, Taiwan
3. Division of Cardiology, Department of Medicine, Taoyuan Armed Forces General Hospital, Longtan, 325, Taiwan
* Author to whom correspondence should be addressed; E-Mail: jchsieh@saturn.yzu.edu.tw;
Tel.: +886-3-4638800 (ext. 2798); Fax: +886-3-4352077.

Abstract: 12-lead electrocardiography (ECG) has been

one of the most commonly used clinical diagnostic tools
in cardiology. However, 12-lead ECG and its
management system cannot meet the demands of ECG
interoperability, nor can it help facilitate real-time ECG
tele-consultation services and the clinical diagnostic
supporting system. Therefore, it is vital to develop a new
ECG management system which serves to solve the
aforementioned problems. This study applied mobile and
cloud computing to establish a basic framework of
12-lead ECG information system. This system allows
ECG to be operated in picture archiving communication
system (PACS) with the standard, digital imaging and
communication in medicine (DICOM), which facilitates
both data and system interoperability across hospitals
around the globe. In addition, this study proposed a

structured format in accordance with DICOM-ECG,

which includes the cardiologists qualitative and
quantitative ECG measurement reports. The proposed
structured reports can be compiled as the databank for
big data analysis and the development of intelligent
diagnostic supporting system. This system is proved to
be secure and convenient to use. In conclusion, this
system facilitates data and system interoperability among
hospitals,
promotes
ubiquitous
tele-consultation,
improves telemedicine services, and paves the
foundation to develop an intelligent 12-lead ECG
diagnostic supporting system.

1.
Introduction
1.1 12-lead ECG in Clinical Practice

technology [5]. New technology for faster and smarter

services such as ECG interoperability across hospitals
and ECG tele-diagnosis is in great demand.

Digital imaging & communication on medicine (DICOM),

the standard developed by the National Electrical
Manufacturers Association (NEMA), has been widely
used for the storage and management of medical images
in clinical practice [1-2]. The delivery of medical image
files has to rely on Picture Archiving communication
system (PACS), which uses DICOM as its data
communication protocol [3]. In 1999, NEMA established
the DICOM-ECG standard for waveform typed ECGs [4].
However, ECG data formats are still divergent, most of
which are vender-specific. Meanwhile, the e-management
of ECG files depends on vender management software.
As a result, interoperability of ECG data has been
difficult to realize, and scientists cannot gain easy access
to ECG waveform data to develop new technology of
long-distance ECG diagnosis and data management. In
the past decade, the technology of mobile computing and
cloud computing has made great impact on the
development of 12-lead ECG data management

Keywords 12-lead ECG, DICOM-ECG, PACS, structured

reports

1.2 12-Lead ECG Telemedicine and Interoperability in Clinical

Practice
In our consideration, medical services should utilize the
technology of mobile computing and cloud computing.
For example, physicians in ER or ICU need timely
consultation from off-site cardiologists who can receive
and review medical files to make the appropriate
assessment and diagnosis [6-9]. Another example is the
disposition of patients on the ambulance, who can benefit
from pre-hospital diagnosis conducted through the use of
mobile consultation and the exchange of medical
information between the ambulance and the mobile
phones of off-site senior physicians [10-12]. With regards
to the patients at home who suffer from cardiovascular
diseases, they can also benefit from timely
mobile-consultation and appropriate long-distance
medical services, which not only reduce the cost of

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Figure 1. A private cloud computing based 12-lead ECG information system

readmission but decrease the fatality rate [13-14]. In

summary, 12-lead ECG tele-diagnosis is a cost-effective
method to reduce expenses and enhance efficiency and
quality of medical services [15].
Cloud computing is a new service to deliver computing
resources, with which providers use virtualized
technology to transform physical computing resources,
such as CPU, memory, and networking into web
available resources [16]. Therefore, general users can
easily use web browsers to deploy user-developed
applications for public use on the cloud. The use of cloud
computing not only reduces the expenditure of
purchasing and maintaining hardware and software but
also decreases the waiting time for the setup. Another
benefit of cloud computing is the facilitation of
cooperation among organizations and groups of
individuals, who can share or rent these resources to
access, compute, manage, store, and exchange data with
minimum cost. For example, cloud-PACS can offer
medical imaging storage and management services for
small hospitals or clinics in rural areas [17-18]. A recent
study also shows that the use of cloud-computing
platform will enable inter-hospital cooperation, facilitate
ECG data exchange, and improve long-distance ECG
tele-consultation services [19].
1.3 12-lead ECG Structured Reports
Physicians need to keep medical reports including
patients diagnoses and treatment after reviewing ECGs.
However, the report writing is usually text-free, which
has no specific format and content requirement. As a
result, medical notes may not be easy to read and reuse.
In addition, medical reports are stored separately from
ECG files. These problems cause the difficulty in data
collection and comparison of ECG and medical reports,
as well as management and retrieval of diagnostic
information.
The structured reports (SRs) refer to those with specific

templates, standardized medical vocabulary and

diagnostic codes [20]. SRs are convenient for physicians
to record their medical findings and dispositions. Resent
research indicated that as compared with the traditional
paper medical reports with medical image files, SRs can
present medical findings more clearly [21-22].
Additionally, SRs are suitable for data mining with the
purpose to quickly identify abnormal images and
unusual cases [23]. That is, these benefits can not only
improve medical service quality and data management
but also facilitate medical education and consultation.
NEMA has established the ECG SR templates, which
include the patients clinical history, ECG measurement
technology, ECG comparison with previous examination,
ECG observation, and the summary of ECG
interpretation [24]. In short, a DICOM ECG SR is
convenient to use and contains structured and important
medical information. DICOM ECG SRs can be
incorporated with DICOM ECG in PACS, which makes
data retrieval and comparison easy and set up the
foundation for the future development of an intelligent
diagnostic supporting system with big data.
Cloud computing offers low-cost outsourcing data
storage and facilitates the development of big data
analysis technology. The characteristics of big data
include variety, volume, and velocity of data generation
[25]. As big data analysis includes the review of both the
present and the past data, it generates better prediction
and more meaningful interpretation. With the
compilations of SRs and big data analysis, an intelligent
diagnostic and dispositional system may be realized.
The primary purposes of this study include (a) to
establish a 12-lead ECG information management system
with the functions of data interoperability and system
interoperability, (b) to ensure data security and protect
patients privacy when long-distance ECG diagnostic
services are delivered, and (c) to pave the foundation of
the future development of an intelligent ECG diagnostic
supporting system. This project is usable and is currently

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based on private cloud-computing infrastructure. In the

future, this system can employ public clouds to realize
ECG data interoperability and system interoperability
across hospitals around the globe.
2. Methods:
As shown in Figure 1, this study proposes a new 12-lead
ECG information management system, which has been
tested and proved by the Taoyuan Armed Forces General
Hospital in Taiwan since 2013. This system can realize
long-distance ECG telemedicine and ECG system
interoperability, which is consisted of three layers based
on the infrastructure of private cloud computing:
The first layer refers to the ECG access layer, which
allows cardiologists to use computers or mobile phones
to retrieve 12-lead ECGs. To retrieve ECG data, the
personal digital certificate of the physician has to be
entered. The personal digital certificate includes the
personal digital identification and the public key
infrastructure (PKI). ECG transmission within or outside
the hospital is conducted in the encrypted form in the
secure sockets layer (SSL) to ensure patients
confidentiality and data integrity.
The second layer refers to the ECG service layer, where 2
ECG service applications are created and implanted in
two virtual machines (VMs). These two VMs have the
following functions. First, information security is ensured.
Only the certificate issued by the certificate authority (CA)
can have access to this system. Cardiologists need to
verify their certificate before login. The time of login is
recorded with digital signatures. Second, an ECG
workflow service is provided. This machine exports the
data from commonly used ECG devices, such as Philips
XML, GE XML, and Mortara DICOM, and transforms the
data into DICOM ECG via decryption of the waveforms.
This machine then imports these data for storage in PACS.
Cardiologists can use PACS to look up ECG, medical
image files, and perform data exchange across hospitals.
Table 1 summaries the clinically-used ECG file formats,
the algorithms of ECG waveform encryption and
compression, as well as the size of the ECG files.

Format
Waveform
Compressi
on
Waveform
Encryption
Sampling
rate
File size

HP
Pagewriter
Vendor-speci
fic binary

Philips Trim

GE MAC

Vendor-speci
fic XML

Vendor-speci
fic XML

Mortar
a
DICO
M

Huffman

LZW

No

No

No

Base 64

Base 64

No

250HZ

500HZ

500HZ

~40 KB

~230 KB

~110 KB

1000
HZ
~280
KB

Table 1. The specifications of clinically-used 12-lead ECG.

Figure 2 shows the 12-lead ECG SR templates based on

DICOM standardization part 16 [24]. This SR serves as
the 12-lead ECG clinical diagnosis guideline. It consists of
hierarchical templates. Each template indicates the
content that the cardiologist has to enter, which contains
the qualitative and the quantitative information. The
qualitative information includes the specific medical
vocabulary and diagnostic codes for cardiologists to
select. For instance, template 3701 records the patients
condition, reasons for referral, medical history, and
medication records. TID 3702 records the comparison
between the current findings and the previous findings.
TID 3708 records ECG specification and device setup.
TID 3713 records the ECG diagnostic results. TID 3719
notes whether the findings are abnormal and the degree
of severity. The quantitative information is mainly based
on TID 3714, which records the measurement of the
global ECG parameters, such as QRS axis, and the
measurement of each lead, such as the amplitude and
duration of p wave, ST60, and ST slope. As the
measurement of each lead feature is time consuming, the
investigators of this study develop algorithms to
automatically remove ECG noise, correct ECG baseline
and delineate ECG to extract ECG characteristic points,
such as P, QRS, T, and J points. Therefore, the
quantitative ECG measurement in TID 3714 can be
estimated automatically. A complete DICOM-ECG
diagnostic report requires cardiologists to offer
qualitative and quantitative measurement results.
DICOM-ECG and DICOM-SR are international standards
and can be incorporated in PACS across hospitals. With
the incorporation of the DICOM SR format and
DICOM-ECG in PACS, the reports are easy to retrieve
and deliver for inter-hospital consultation and research.
The third layer is called the infrastructure layer.
DICOM-SR contains the qualitative and the quantitative
information that are convenient for data mining. As the
ECG SRs are compiled, researchers need a distributed file
system, such as Google proposed Mapreduce technology
that can speed up data processing [26]. Hadoop is an
open source software that can realize Mapreduce
technology and can be implemented on private cloud
computing and public cloud computing platforms, such
as Windows Azure and Google App Engine [27-29]. In
this study, we developed a private cloud computing
infrastructure with Hadoop based on Microsoft windows
server 2012, and this platform can be developed further
as the basis of ECG clinical diagnostic supporting system.
3. Results
3.1 12-Lead ECG Diagnosis on PACS
As shown in Figure 3a, a cardiologist is manipulating
PACS to review and diagnose the patients ECG on the
right computer, while scheduling the patients next
appointment in the radiology information system (RIS)

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Figure 2. The templates of a DICOM based ECG structured report.

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on the left computer. In this way, the cardiologist can

diagnose the current ECG and schedule the next ECG
exam in PACS and RIS as the same workflow of the
medical imaging diagnosis. Figure 3b shows the records
of auditing database as described in the second section of
methods. This database records the cardiologists
activities on PACS, including the login and the logout
schedules, which are confirmed by the cardiologists
digital signature.

deliver telemedicine services. Integration of waveform

based ECG and pixel based medical imaging on a unified
DICOM can enhance diagnostic accuracy and treatment
efficiency as clinicians can easily and ubiquitously
manage and review ECG and images on their mobile
devices.

This digital signature is generated by the cardiologists

PKI and is non-repudiation. To ensure the system
security and protect the patients data, it is essential to
monitor unusual activities on PACS.

Figure 4a. Secure access of ECG and images on a tablet.

Figure 3a. The use of DICOM-ECG on PACS and RIS.

Figure 4b. A coronary image on a tablet.

Figure 3b. The monitoring of users activities on PACS.

3.2 12-Lead ECG and Medical Imaging Diagnosis on Mobile

Devices
Figures 4a to 4c show the secure access of ECG and
medical imaging across public networks via a mobile
device. A PKI contains an authorized digital certificate
for the identification of the cardiologist and keys for data
encryption and decryption, which is implemented on the
cardiologists mobile phone or tablet. As shown in Figure
4a, a certificate is authenticated when the cardiologist is
trying to access ECG or images stored in PACS. Once this
authentication is validated, the ECG and medical imaging
transmission between PACS and tablets will be
conducted in secure sockets layer (SSL) where ECG and
images are encrypted. After the ECG is transformed into
the DICOM format, the ECG and imaging diagnosis can
be conducted on the same DICOM viewer. Figure 4b and
Figure 4c show a coronary image and a 12-lead ECG on a
tablet, respectively. In summary, mobile devices, such as
smart phones and tablets, have become essential tools to

Figure 4c. A DICOM-ECG on a tablet.

3.3 12-Lead ECG Structured Reporting System

As shown in Figure 5a, the characteristic points of ECG,
such as P, QRS, and T points, are identified automatically,
and the baseline is also recognized. The sensitivity of
QRS detection is 99.51% in 23390 beats, the sensitivity of
P detection is 95.48%, and the sensitivity of T detection is
97.96%. Figure 5b is an example of DICOM-ECG SR,
where the cardiologist selects a pre-defined code to
describe the trend of this ECG in TID 3713. Figure 5c is an
illustration to conduct ECG ST slope measurement in TID
3714. In Figure 5c, the cardiologist uses the interactive

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Moving Toward Data and System Interoperability in Tele-cardiology: Using Pacs Compatible 12-lea...

tools
to
correct
the
errors
resulting
from
computer-assisted ECG waveform measurement in TID
3714.

Figure 5a. Automatic ECG delineation and baseline recognition.

Figure 5b. An example of a 12-lead ECG structured report.

to realize ECG interoperability and to enhance the

services of telemedicine.
Cloud computing is
highlighted with easily scalable computing resources and
storage capacity through VM technology, as well as with
highly available and accessible services through web. As
shown in Figure 6, implementing PACS in the cloud can
be a promising service model to facilitate ECG
interoperability and to enhance the service quality and
efficiency of telemedicine. This cloud PACS can be served
as an ECG hub to deliver ECGs to the PACS among
hospitals when the patient needs to be transferred from
one to another hospital. The cloud-PACS can also be used
as an ECG tele-consultation service hub, which timely
redirects the ECG transmission from the ambulance or a
remote clinic to the mobile devices of an experienced
cardiologist. Most importantly, the cloud-PACS can
expand the ECG service range from local to global. In this
study, we developed a secure ECG retrieval across public
networks with the authorized certificate and PKI. This
technology reduces the risk of exposing the patients data
across public networks. Unauthorized access is prevented
through data encryption, the authentication of certificate,
and the monitoring of unusual activities on this system
via digital signatures. Once a secure data retrieval
mechanism is established, the adoption of cloud
computing technology in hospitals is feasible and
beneficial.
4.2 ECG Structured Reports and Clinical ECG Diagnostic
Supporting System

Figure 5c. ECG measurement in TID 3714 of a DICOM-ECG

structured report.

4. Discussions
4.1 The Data and System Interoperability of 12-lead ECG
To date, the development of 12-lead ECG is still hindered
by heterogeneous ECG formats and its management
system. In clinical practice, a vender-specific ECG device
equipped with its management system is not compatible
with other vendors ECG devices and management
systems. At present, PACS is widely used in most
hospitals for storage, exchange, and transmission of
DICOM based medical images. The integration of ECG
and medical images into the PACS format is a
cost-effective way to facilitate ECG data and system
interoperability.

Recent studies in genome research community have

addressed the importance of building structured gene
data and the annotation of gene sequence for big data
mining [30]. Similarly, structured ECG reports are
needed to develop a clinical diagnostic supporting
system, as SRs contain unified medical vocabulary and
diagnostic codes and provide the patients status
description and ECG features with the quantitative
waveform measurement.
In this study, we proposed a private cloud computing
based 12-lead ECG management system, which can be
easily implemented on public cloud computing platform,
so to facilitate ECG interoperability and ubiquitous
tele-consultation in a cost-effective way. We also
proposed DICOM-ECG SR, which serves as the
foundation for the development of intelligent clinical
ECG diagnostic supporting system. Importantly, this
DICOM-ECG SR can be integrated in PACS with
DICOM-ECG and is reusable. In our consideration, the
adoption and practice of these systems and DICOM-ECG
SR will form the basis of big ECG data analysis in the
near future.

The technology of cloud computing is another key factor

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Figure 6. 12-lead ECG telemedicine and interoperability via a cloud ECG service.

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