Mobile Mules: Modular E-Health Information
Synchronization Framework
Abdel-Karim Al-Tamimi
Computer Engineering Department
Yarmouk University, Jordan
altamimi@yu.edu.jo
AbstractProviding the capability of connecting and
transferring information between geographically separated
health centers is one of the major contributions of ICT
researchers in the health sector. The utilization of this
advancement is hindered by the low penetration of Internet
services in developing countries and especially in rural areas.
Taking into consideration the recent advances and the wide
spread of mobile technologies and devices, we present in this
paper an innovative method and a fail-safe system design to
securely and seamlessly transfer and synchronize information
and data records between E-health datacenters. The proposed
system architecture is scalable and takes into consideration the
interoperability problem that emerges when connecting different
E-health systems. The proposed solution utilizes the recent
advances in both mobile and web-based services.
Keywords Data communication; Web services; Information
management; Information security; Mobile ad hoc networks;
Interoperability; E-health services; E-health records.
I. INTRODUCTION
This paper presents an innovative solution to the problem
of transferring data records and information securely between
geographically separated datacenters, especially when data
communication services are scarce or expensive to be
considered as a viable mean for transferring information. In
this paper, we propose a modular framework that utilizes
mobile phones as data carriers to exchange data records
between data centers. Mobile phone services are considered a
major player in transferring data even in developing countries,
as the penetration of mobile phone services exceeds the
penetration of landline phone lines. For example, in Africa the
number of mobile phone subscribers is 32 times the number of
landline subscribers [1].
While electric grid spread covers wide areas in developing
countries, the spread of capable Internet and mobile networks
that can support data transfer is still limited [2]. With the wide
spread of mobile phones usage and the continuing decrease of
the prices of computational capable smart phones, that recently
reached sub-100$ price tag, it is feasible to consider smart
phones as a practical mean to manipulate and transfer data
records between datacenters, and thus acting as data mules.
Nowadays, mobile phones come with relatively large storage
spaces that can be sufficient for most data transfer applications.
The challenge of transferring data records and especially e-
health records is of a great importance for both developed and
Ala Khalifeh
Electrical and Computer Engineering Department
German Jordanian University, Jordan
ala.khalifeh@gju.edu.jo
developing countries. Even with the spread of advanced
networks in the developed countries, the boundaries of good
broadband services are usually limited to highly concentrated
population centers like big cities and dense municipal areas;
and do not extend to rural areas. This is due to the higher cost
of infrastructure, or/and the lower returns on the infrastructure
investments in sparsely populated areas [3]. Transferring data
records between datacenters require researchers to assure the
accuracy, the security, the interoperability, the scalability, and
the viability of the chosen means of data transfer.
Transferring and synchronizing data is of a great
importance to e-health services. For instance, the
synchronization of data records is necessary to keep track of
the levels of vaccines stocks and supplies amounts [2]. Such
information is important to be kept updated to assure the
delivery of vaccines and medicines to patients. In addition,
patient information and other medical records are usually
communicated to follow epidemics spread to take the necessary
countermeasures.
Using simple methods to transfer data by simply utilizing
portable data storage devices face many technical and security
challenges and concerns. First, these devices normally require
physical access to both source and destination services
(typically a server), which raises a lot of concerns about data
security and the possibility of spreading viruses and malicious
programs. This possibility increases in rural areas that usually
have a limited access to the Internet, which limits their ability
to update the level of datacenters security and readiness to face
new security threats.
In addition, moving data records from one system database
to another is not a trivial task and requires a high level of
technical competency. For example, sending entire hard drives
to transfer data requires a high level of technical proficiency on
both local and central datacenters sides, and requires a
considerable amount of resources. This includes the ability to
disconnect and re-attach hard drives safely, the ability to copy
the required data records and the ability to synchronize the
different databases. In addition, the possibility of spreading
malicious programs and viruses still exists. Sending the data
using read-only media is still a technically demanding method,
and exposes the system to unwanted viruses and programs that
can be copied from any compromised datacenters.
Current approaches of transferring data between datacenters
either require expensive equipments or/and rely on inefficient
means for both short and long-term setups. This is more
evident especially when there is a need for transferring large
amounts of data. Thus, any proposed solution should make sure
that only the minimum number of data records is transmitted to
ease the transfer process and allow a better maintenance of the
synchronization level between datacenters.
Several approaches to solve the data connectivity problem
in rural areas have been proposed in the recent years. One of
the solutions proposed is the use of short message service
(SMS) messages as a means to transfer data between
datacenters when the data amount sent is assumed always to be
of a small magnitude [2]. Another popular approach is to
connect rural areas datacenters with central datacenters using
satellite communications. This approach assumes the ability of
the rural communities to pay both initial and annual recurring
costs. These costs are considered expensive, especially for
economically challenged communities [4].
In this paper, we describe our proposed system that is based
on a modular design and is divided into interchangeable
components. The system architecture allows mobile phones or
any Internet-enabled device to consume the offered data
synchronization services and act as a data mule to carry data
records between datacenters. In addition, we demonstrate how
the system design decisions assure the lowest coupling possible
between the different modules, which allow better scalability
and maintainability levels.
This paper is divided as follows, the next section will
describe our proposed framework architecture and how it
compares to other proposed solutions in literature. In addition,
it provides a detailed explanation of the synchronization
process. Section 3 discusses the mobile application design as
one of the possible data consumers of the proposed
architecture, and the testing scenarios performed to verify the
applicability of the system and its ease of use. Section 4
concludes this paper with our conclusions and a brief
discussion of other possible applications of the proposed
system.
II. MOBILE MULES FRAMEWORK ARCHITECTURE
Many environmental and technical factors need to be
addressed when designing a new system for transferring data
records and especially when targeting rural areas [11]. One of
them is the low reliability and the low coverage of data
transmission media in rural areas. When there is a need to
transmit high volumes of data that are usually associated with
patients records, sending data over mobile SMS is considered
an expensive mean. Since SMS message size is limited to only
161 characters. Thus, the high cost of sending SMS messages
can be a major prohibiting factor to consider this approach [2].
On the other hand, Global System for Mobile communications
(GSM), which has the highest coverage in developing
countries, provides a low bandwidth connectivity of only 10-
50kbps and its services are considered unreliable in many
countries [4].
Another proposed mechanism is to use a combination of
technologies like WiFi, for local centers, and WiMAX, as the
backhaul media, to transfer data. Such a setup is estimated to
cost initially around $125,000 with a recurring annual cost of
$8,500. Such amounts are considered as a hefty sum for most
developing countries [4]. Another commonly proposed
approach to tackle the problem of transmitting data to/from
rural areas, as we have mentioned earlier, is the use of satellite
communications. This approach is also considered as an
expensive solution for developing countries. As satellite
communications requires both high installation prices and
considerable amounts as recurring costs.
One of the main concerns when transferring critical
patients' information is to assure data anonymity, and provide a
high level of security as required by the World Health
Organization (WHO) [4]. Another main challenge when
providing an e-Health service is to assure its interoperability
with existing Healthcare Information Systems (HISs). This is
due to the fact that the technologies the healthcare information
systems are based on may differ greatly [5]. The use of
proprietary formats is another major cause of the
interoperability problems. In addition, using different standards
has the same effect. For example, systems based on Health
Level 7 version 2 standard are incompatible with systems
based on Health Level 7 version 3 systems [6].
One of the industry major initiatives to overcome
interoperability problem is to store and expose data using
XML-based infrastructure that is commonly referred to as
Electronic Business XML or ebXML. This standard is
supported by OASIS and UN/CEFACT to provide an open,
secure and interoperable infrastructure [10]. This approach is
also enforced in the integrating Healthcare Enterprise Cross
Enterprise Document Sharing (IHE XDS) systems [6]. Using
XML-based systems allows better interoperability between
systems regardless of the used technology and provides a
higher level of maintainability for patient records. When
transferring data over expensive and limited capacity media, it
is important to transfer only new or recently modified data
records. This allows central datacenter(s) to be synchronized
with peripheral datacenter(s) efficiently. Moving a subset of the
data minimizes the transferring cost, but at the same time
introduces the problem of assuring that the transferred data is
mirrored on all the interested parties accurately.
Mobile service providers and developers provide different
means to synchronize personal contacts, emails, and other
information with their PCs [7]. Several projects are aiming at
providing database accessibility for mobile users as in the
Amsler Project [8]. Amsler provides the means to perform
record replications between MySQL servers and Android-
based devices equipped with SQLite database. Amsler project
requires a direct connection to the source database, which
raises several interoperability and security concerns. In
addition to that, Amsler requires the mobile phone to have a
mobile version of an SQL server, which is not guaranteed on
all mobile operating systems, and adds a layer of complexity in
handling exchanged data.
Our proposed solution tackles all these concerns by
introducing a modular framework that allows different and
geographically separated systems to communicate and
synchronize their data. In our framework, we assume that rural
datacenters have access to electricity power at least.
Developing countries can have access to electricity from
various sources like solar, hydroelectric, fossil fuel, geothermal
and wind energy [4]. In addition, in the developing countries,
the widespread of electrical grid exceeds Internet and mobile
communication grids [2].
We also assume that healthcare personnel make frequent
travels to central datacenters locations, which are usually
located at the governance center or at the capital, or any
Internet-serviced area. Such visits are usually made for various
personal and professional reasons. We also assume that the
travelling personnel carry WiFi/3G/4G enabled devices. Such
an assumption is not farfetched as we have discussed before
with the low prices of such smart phones.
Fig. 1. Proposed system architecture
Figure 1 shows the proposed system architecture. The
framework consists of three main parts: a local datacenter that
is usually located in rural areas, a central datacenter that is
usually located in governance central with Internet availability,
and a smart phone device that act as a data mule that carries
and synchronizes information between the local and central
datacenters.
Using mobile agents such as people, vehicles or even
animals have been proposed before in the literature to provide
wide-area connectivity for sparse sensor networks at the
expense of higher latencies [9]. These systems usually consist
of three tiers: a bottom tier that represents the scattered fixed
wireless sensor nodes. The middle tier represents the moving
mobile agents, who have the capability to connect to the other
two tiers. The top tier is usually represented with WAN
connected devices.
As can be noted from figure 1, we assume that the local
datacenters have WiFi network capabilities, which is
considered as a viable communication method in rural areas
[4]. The local datacenter setup is considered inexpensive and
easy to maintain. Once the required services are set, there is
little to no changes needed to be made to assure the availability
of the service. The central database center is assumed to have a
better access to variety of data communication media such as
WiFi, 3G and 4G. The geographical area that separates the
local and the central datacenters is assumed to have either
expensive communication media that inhibit transferring large
amount of data records, or no data connection media at all.
The local datacenter comprises of a PC with a database
server that holds local health center information: patients'
records, supply and vaccines quantities, and personnel records.
The PC also hosts a webservice that acts as a gateway to the
information stored in the database. The webservice exposes the
data using XML-based format to assure the highest
compatibility with other systems and devices. In addition, the
webservice exposes the schema or the design of the database to
ease conducting semantic matching between different
databases when necessary using XML Schema Definition
(XSD) file format. As an alternative to using XML, the
currently popular standardized data encapsulation format:
JavaScript Object Notation (JSON) can be used.
The central database has a similar setup with the exception
that the webservice can be accessed with more means than
WiFi, including 3G and 4G communications. The webservice
can be hosted using cloud platforms, like Windows Azure [12],
or using a simple webservice depending on the required
processing capabilities.
The synchronization process between datacenters consists
in its simplest form of three actions that resemble a
handshaking mechanism between the local datacenter and the
central datacenter: first, synchronize to the local datacenter to
retrieve new data records through the available webservice
over WiFi. The second action is to synchronize to the central
datacenter over the available WiFi/3G/4G communications.
The third action to re-synchronize to the local datacenter to
confirm the completion of the data records transfer. In the
following subsections, we will go into more details about each
of the synchronization steps.
A. Synchronizing to Local Datacenter
In this step, the healthcare person uses his/her phone to
synchronize to the local datacenter. Only new or modified
records since the last synchronization process are transferred to
the mobile. This means that only a differential snapshot of the
data is carried on the phone. Data communication and storage
is secured on both sides, mobile application and data centers,
with the use of public and private key encryption mechanisms.
Other security measures can be easily incorporated to ensure a
higher level of security and better authentication mechanisms.
For instance, certain security rules can be implemented to
allow only certain devices to access the webservice depending
on their MAC addresses. All transmitted data records are stored
on the phone in an encrypted format to overcome any security
issues resulting from stolen, lost or compromised phones.
To keep a track of the modified and new records, two data
columns are to be appended to the synchronized data tables.
The first column is LastModified which indicates the last time
the record was modified (when performing insert or update
actions). The second column is SyncStatus which indicates the
synchronization status of the data record. When the data record
information is created or modified, the column value is set to
Modified.
Once data records are transferred to the mobile phone their
SyncStatus column statuses on the local datacenter are set to
SyncPending. Other data mules are also allowed to
synchronize to the local datacenter and receive all data records
that their synchronize statuses are set to either Modified or
SyncPending. This allows multiple data carriers to collaborate
in synchronizing data between datacenters without
compromising the accuracy and the recency of the data.
B. Synchronizing to Central Datacenter
When healthcare personnel visit the location of the central
datacenter or any Internet-serviced area, they can use their
phones to synchronize to the central database. The data transfer
is done using the available webservice or cloud-based service.
The central datacenter can have a similar level of security as
the one discussed before for the local datacenter.
The data records transferred to the central database are
checked first to see if it is newer than the currently available
data records. If it is newer, the data records are synchronized
and the last modification date is set to the date specified in the
transmitted records. Since in the case when there is more than
one data carrier, it is possible to have a data carrier that arrives
at time ( t t 0 ) and carries an older version of data records
than a data carrier that arrived at ( t t0 ). Once the
synchronization process is completed, all data records statues
on the mobile phone, (i.e. the entire differential data snapshot),
are set to SyncedToCentral.
C. Re-Synchronizing to Local Datacenter
This stage is necessary to complete the handshake
mechanism between the local and the central datacenters. By
re-synchronizing to the local datacenter, the webservice
verifies that all the transferred data has been synchronized
correctly to the central database. Local datacenter data records
that are still marked as SyncPending are the only ones to have
their statuses changed to Synced status. If the data records sent
to be synchronized with the central database change during the
synchronization process, their status values change from
SyncPending to Modified. This mechanism assures that data
records when they change, while the synchronization process is
taking place, do not get marked as Synced.
In this section, we described the architecture of our
proposed system and the three-step handshaking mechanism
that assures that data records are synchronized correctly. The
proposed mechanism assures the recency of data even when
data records are synchronized using multiple mobile devices.
In the next section, we discuss the implantation of our system
and the testing process and the obtained results.
III. SYSTEM IMPLEMENTATION AND TESTING
Our system implementation has been divided into three
phases: creating an E-Health system that comprises of two
local datacenters and a central datacenter. Then creating three
webservices (two local and one central webservices) to allow
the used mobile phones to access and synchronize data with the
local and central databases. Local datacenter webservices were
implemented using ASP.NET SDK 3.5, and the central
webservice was implemented using Windows Azure cloud
platform [12]. The usage of cloud-based services allows faster
information convergence, especially when multiples of mobile
mules are connected simultaneously, and better computational
capabilities on the central datacenter side that can be used to
gather information about local data centers and process them to
provide better future services. Finally, a windows phone
application was created to resemble a possible data mule
application with the needed functionality to carry and
synchronize data records.
The proposed system can also be easily integrated into
existing systems by creating the required webservices, with
minimal modifications to their database tables (i.e. the addition
of the SyncStatus and LastModified data columns). The
webservices can then connect to the existing databases and
expose its contents securely. The webservice creation can be
customized to the datacenter or simply auto-generated using
dialog-based applications. Such applications require the
address of the database server and its login credentials, the
database to be synchronized and the tables to be synchronized.
The total cost of the proposed communication framework
hardware, in its simplest form, is less than $200, where $100 is
for the used mobile phone, and $50 for each of the WiFi access
points (one for the local datacenter and one for the central
datacenter). This if we assume that the central datacenter is not
to be accessed using the available Internet infrastructure. The
cost of systems maintenance is minimal, since the used
hardware and software setup is greatly simplified.
It is important to note that the used technologies in our
testing can be replaced with newer and better technologies as
needed to meet the requirements of the E-health system while
maintaining the general framework of the solution. As an
example, as we discussed earlier, JSON based webservices can
replace the used XML-based services. In addition, the WiFi-
based communications between the mobile phone and local
datacenters can be substituted with other medium like
Bluetooth or Near-field Communication (NFC) if necessary.
The three tested datacenters reside in three geographically
separated places in Jordan as shown in figure 2. The distance
between the local datacenter (A) [Mgheir, Irbid] and the central
datacenter (B) [Yarmouk University, Irbid] is 10.1 km, and the
distance between central datacenter and the local datacenter (C)
[Al Ashrafyeh, Irbid] is 25.9 km. While our system testing
does not necessitate distant geographical locations for the
datacenters, we considered this testing scenario as a good
exercise to test the battery usage and the convenience of using
the service in real world scenarios.
Fig. 2. The geographical distribution of the tested datacenters
 We have implemented the Mobile Mules client application
using Windows Phone 7.1 SDK as shown in figure 3. In our
testing we used two LG Optimus 7 phones running Windows
Phone OS version 7.5. The application has a minimalistic
design and contains two pages: the main page is where the user
can synchronize to the local and central datacenters and
overlook the synchronization process progress. The second
page is the settings page, where the users can update the
webservices URL paths for the datacenters when necessary.
Fig. 3. Mobile-Mule mobile application
We have conducted several experiments to measure the
speed of the synchronization process with different magnitudes
of data records and their battery consumption. Table 1 details
the average time required in milliseconds to synchronize the
data records to a datacenter. We have chosen the worst
scenario, where all the records have been recently modified and
thus are needed to be synchronized. Patient data records
information were randomly generated and each has 1KB of
information. Phone-webservices communications were
performed over IEEE 802.11g WLANs. Each of the testing
scenarios has been repeated 15 times and we calculated the
mean and the standard deviation of the recorded times. The
selected numbers of records in these experiments were chosen
after surveying local health centers personnel of the typical
weekly and monthly modified records numbers.
TABLE I. MOBILE MULES SYNCHRONIZATION TEST RESULTS
Number of Data Time to Synchronize (ms)
Records Average Time (ms) Standard Deviation (ms)
50 471.4 144.5
100 472.6 85.5
500 1500.7 175
1000 4849.1 316.6
5000 35366 1180.6
As can be noted from table 1, the time needed to
synchronize data records is less than a second for 100 records,
and it barely exceeds half a minute when synchronizing 5,000
records. It can also be noted that there is a small difference
between the time recorded for 50 records and 100 records. This
is because there is a minimum time required to establish the
connection between the phone and the webservice regardless of
the number of the records to be synchronized. The battery
usage in all the tested cases was negligible (less than 1% drop
of battery status after each test run), which supports our claim
of the system high performance and applicability in real time
scenarios. The overall feedback from the testers indicated the
solution high level of usability and a seamless synchronization
process. In the next section, we will conclude our paper and
discuss some of the possible applications of our system that
stretch beyond e-health services.
IV. DISCUSSION AND CONCLUSIONS
In this paper, we present a viable solution to transfer and
synchronize data records between datacenters securely and
effortlessly. The system's modular design allows the integration
of different technologies to achieve a high level of security,
interoperability, and usability. The usage of cloud platforms
can allow a faster information convergence and better
processing capabilities to be performed on the gathered data
records. Although the main aim of this proposed solution is to
connect and transfer data from rural datacenters, the system can
also be used when there are security concerns for sending data
over the Internet. The applicability of this design extends the
realm of E-health systems, and can also be used to synchronize
any geographically separated datacenters while providing the
necessary security and authentication levels.
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