Design and development of improvised cloud based rural health care system

For registration to the degree of

Doctor of Philosophy

IN THE FACULTY OF SCIENCE

THE IIS UNIVERSITY, JAIPUR

Submitted by

(Ahimsa Vyas)

Under the Supervision of

(Dr. Vijay Singh Rathore)

Designation: Director Karni College

Computer Science Department

April 2013
 1. Topic
“Design and development of improvised cloud based rural health care
system”.

2. Introduction
Cloud Computing:
Cloud computing is a model for enabling convenient, on-demand network access to a shared
pool 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. This cloud model promotes availability and is composed of five
essential characteristics, three delivery models, and four deployment models.

The five key characteristics of cloud computing include on-demand self-service, ubiquitous
network access, location-independent resource pooling, rapid elasticity, and measured service, all
of which are geared toward using clouds seamlessly and transparently. Rapid elasticity lets us
quickly scale up (or down) resources. Measured services are primarily derived from business
model properties and indicate that cloud service providers control and optimize the use of
computing resources through automated resource allocation, load balancing, and metering tools

The three key cloud delivery models are software as a service (SaaS), platform as a service
(PaaS), and infrastructure as a service (IaaS). In IaaS, the cloud provider supplies a set of
virtualized infrastructural components such as virtual machines (VMs) and storage on which
customers can build and run applications. The application will eventually reside on the VM and
the virtual operating system.

Cloud deployment models include public, private, community, and hybrid clouds.

Cloud Computing benefits in healthcare

From medical point of view, cloud offers special channel to easily access electronic medical
records. This ability of quick access to personal medical history can speed up treatment, help to
avoid complications, and even saves lives. Cloud also can make it easy for the patients to locate
and keep track of their own health record.

In an effort to improve the nation’s health IT infrastructure, the Department of Health and
Human Services’ (HHS) Office of the National Coordinator for Health Information Technology
(ONC) recently selected a cloud computing platform to manage the selection and implementation
of Electronic Health Record (EHR) systems across the country.

Non-health care organizations as Google and Microsoft provide a means by which consumers
can create an online personal health record (“PHR”). Google Health and Microsoft Health
Vault allow the public to create, store, and access online personal health records on the search
engine's website. [8][9]

3. Review of Literature
Application of Cloud Computing in Healthcare

The majority of physicians in healthcare do not always have the information they require when
they need to rapidly make patient-care decisions, and patients often have to carry a paper record
of their health history information with them from visit to visit. To address the problems, IBM
and Active Health Management collaborate to create a cloud computing technology-based
Collaborative Care solution that gives physicians and patients access to the information they
need to improve the overall quality of care, without the need to invest in new infrastructure [1].
IBM facilitated American Occupational Network and HyGen Pharmaceuticals to improve patient
care by digitizing health records and streamlining their business operations using cloud-based
software from IBM Med Trak systems, Inc. and The System House, Inc. Their technology
handles various tasks as a cloud service through the internet instead of developing, purchasing
and maintaining technology onsite [2].
Acumen solution’s cloud computing CRM and project management system were selected by the
U.S. Department of Health & Human Services’ office implementation of EHR systems across
the country. The software will enable regional extension centers to manage interactions with
medical providers related to the selection and implementation of an EHR system. Sharp
Community Medical Group in San Diego will be using the collaborative Care solution to change
the way physicians and nurses access information throughout the hospital group’s multiple
electronic medical record systems to apply advanced analytical and clinical decision support to
help give doctors better insight and work more closely with patient care teams [2].
One of similar example of applying cloud service in the healthcare area is the architecture of the
hospital file management system (HFMS). A HFMS cluster contains a master server and
multiple blocks of servers by multiple client access [4]. HFMS application software can achieve
optimal performance and availability as shown in figure
The challenges are Stability of operations, data inter operatibility , information privacy handling
internet bugs, s/w licensing .Therefore, the common security challenges faced by healthcare
research cloud applications are less governance, data lock-in, lack of patient consent and
authorization, lack of standard technologies and solutions integrity and key management
procedure.
The application of mobile devices for pervasive healthcare information management [13]has
already been acknowledged and well established ([6], [7]). Authors in [3] present the benefits of
using virtual health records for mobile care of elderly citizens. The main purpose of the work is
to provide seamless and consistent communication flow between home health care and primary
care providers using devices like PDAs and Tablet PCs. Smart cards and web interfaces have
been used in [4] for storing patient records electronically. The MADIP system [5] is a distributed
information platform allowing wide-area health information exchange based on mobile agents. In
[8] authors present a mobile platform for exchanging medical images and patient records over
wireless networks using advanced compression schemes. The majority of the aforementioned
works is based on proprietary architectures and communication schemes and requires the
deployment of specific software components. Furthermore, the works focus mostly on delivering
data to healthcare applications and do not address issues of data management and interoperability
issues introduced by the heterogeneous data resources found in modern healthcare systems. The
usage of Cloud Computing provides data management and access functionality overcoming the
aforementioned issues as discussed in previous sections. The concept of utilizing Cloud
Computing in the context of healthcare information management is relatively new but is
considered to have great potential.
To our best knowledge there is no other work in the literature utilizing Cloud Computing for
providing pervasive healthcare information management services on mobile devices.

A Cloud Computing Solution for Sharing Healthcare Information

In recent years, sharing health care information becomes one of essential requirements of
e-health development[14]. To cover this gap, different solutions are presented through different
technologies. This paper proposed a cloud computing solution for sharing health care
information based on Google JeApp Engine (GAE). With the experiment test results, we achieve
interoperability among different healthcare centers and between healthcare providers and
receivers with high stability and availability

Advantages of health care information in GAE Quick development: Google App Engine has
developed framework that allow developers use java and python to develop applications which
can run in GAE. It provides Google Web Toolkit to let developer build web application interface
in GAE quickly and easily.

High Availability: Google provide 100% uptime of GAE, there is no schedule downtime in
their plan. It means e-health application develop in GAE can run every seconds, 24 hours all year
without disaster.

Large Data Table Storage: Google App Engine support large data storage. It can store less
than I million long string data through special data type. Most of the text healthcare data and
smaller than 500KB health related picture files can be stored in GAE.

Application as Web Service: The applications running in cloud computing are typical web
services. It shows healthcare providers and receivers with applications do not need to establish
special passage or access path to link each other. It increases system independence on each
health care organization and home care

Authorized Information: Google App Engine supports authorized information system by using
entity data storage. Through simulation, server allows users register to their own account and
store information.
2) Disadvantage of healthcare information in GAE

Picture Sharing Limitation: According to our experiment results, the GAE upload maximum
around 500KB of picture file, when picture file size increases than 500KB, it will not upload and
give error message. While in Google App Engine SDK, it doesn't support file uploading directly,
but it use the third party plug-in to complete this task and upload and download the picture file
on website. The limitation of picture file is a big challenge for sharing healthcare data since some
of healthcare information contains picture files. However, we just use a free GAE account to test
our data and picture sharing function, it may be solved when using some paid GAE services.

Unpredictable Latency: From the results of data analysis, we can obviously know the latency in
both sending and receiving operation are unpredictable, latency will change day by day.

Relationship between E health and cloud computing

Infrastructure Needs a huge infrastructure A huge computing

to establish different e-health infrastructure with connect,
services access and distribute with
huge no. of small computing
unit
Storage Name access and store large Support use to access large
data quickly and efficiently data quickly and efficiently
Information The service is distributing to Supports use to integrate
every medical institutes, it information from distributing
needs information of medical branches
institutes more integrating
Development Integrate different e-health It support use to build
services to be platform in
Tendency A platform Cloud

3)The multiplicity of categories of target beneficiaries necessitate multiple record keeping

systems leading to plethora of registers to be maintained by frontline workers like ANM, AWW
and ASHA. The task of record keeping is quite onerous, time consuming and taxing as these
frontline health workers are less qualified and less trained. For example, an ANM is expected to
maintain as many as 20 registers. There is a system for tracking pregnant and lactating women
and a separate system for tracking eligible women for use of contraceptive methods, thus there is
a duality and no integration. Moreover, the present system does not track children up to three
years and adolescent girls for which they still have to depend on other tracking systems each
requiring a separate register with little integration. Since, this task is seldom done with care and
tenacity, there are errors and as a result most records are incomplete and erroneous. The reports
generated from these incomplete and inaccurate records render the information unusable for
planning, decision making and control purposes. Also, since the data feeding is carried out
manually, there is ample scope for data fudging and data manipulation. It is therefore, important
to evolve a technology based solution which will obviate need for a number of records and
registers and which allow direct tabulation and conversion of data into effective information
which can be banked upon for panning and monitoring purposes [10]

The NFHS III had also highlighted the abysmally poor utilization of AWC services for children
as well. It says that only one in ten children (0-59 months) were weighed and less than 20
percent of children (0-71 months) received supplementary nutrition. The percentage of children
whose mother received counseling on nutrition was even less. Poor utilization of nutrition and
health services may also be due to poor tracking of pregnant and lactating women and children
under 5. [9]
4. Motivation/Justification and Relevance

The conditions of females in INDIA especially in Uttar Pradesh is not very satisfactory, the
prime role of women is still childbearing. Indian women are suffering from various ailments.
Along with this, malnutrition, lack of Antenatal care and various socio economic conditions is
responsible for high mortality rate during childbirth.
Our work therefore attempts to analyze the problems during pregnancy among married women in
Uttar Pradesh and also tries to examine the health-seeking behavior among these women against
certain socio-economic backgrounds and how to improve the prevailing conditions.
The Millennium Development Goals-India Country Report 2011 forecast that India will fall quite
short of MDG targets to bring down infant and maternal deaths to less than 27 and 109,
respectively, by year 2015.According to the report, 47 out of every 1,000 infants died before
reaching age one in 2010, down from 50 in 2009. This suggests that until and unless we
improved our tracking and follow up systems, not much will be achieved by 2015.

We can see that all these issues can be traced back to poor tracking, follow-up mechanisms.
Technology can be of great use in making effective and efficient tracking, monitoring and follow
up possible.
There are several practical advantages of applying cloud services in health care industry, such as:

 it provides always-on, real-time data collecting;

 it eliminates manual collecting work and possibility of typing errors; and

 it facilitated the deployment process, as wireless networking means no need for cabling
or other physical setup.

5. Objectives

The goal of the research is to implement and demonstrate effective operation of high tech but
affordable recording system (for health indicators and health seeking behaviors, effectively using
bio-matrix, Global Positioning System and e-Health concepts) enabling better tracking, follow
up and coordinated delivery of health services to target beneficiaries resulting in better access to
health information, informed lines of treatment and more accountable systems.
a prototype implementation of a mobile healthcare information management system based on
Cloud Computing and Android OS. The system enables the management of patient health
records and medical images (supporting DICOM format and JPEG2000 coding) and utilizes the
Amazon’s S3 Cloud Storage Service
Based on the situational analysis, it is apparent that appropriate and high tech recording,
storage, retrieval of information and tracking mechanisms may greatly help in improving quality
of RCH services through improved recording, retrieval and sharing of information leading to
improved follow up and coordinated efforts by the health and ICDS on the one hand and making
planning and monitoring more effective as well as systems more accountable on the other.
 Health information technology (HIT) can prove highly effective in evidence based management
of large scale public health problems like malnutrition, family planning and efficient health care
delivery among children and women. The main objective of the research is to pilot and
demonstrate a set of health information technologies which will greatly enhance recording,
retrieval of health information for better and coordinated follow-up, tracking and monitoring and
serving as a reliable database for planning and monitoring purposes with very little chances of
fudging.

The proposed architecture covers the several elements in current systems, such as:
 To analyze the main reasons of failure of improvement of women’s health conditions in
Uttar Pradesh by investigating secondary data obtained from HLFPPT

 To overcome obvious drawbacks like limitation of picture sharing and unpredictable

latency challenges for widely using GAE to e-health development

 To store all medical and health information (data) for mother and child in a ‘cloud’ which
will be accessible at all referral centers through internet. That will improve the latency
and stability of different operations while transferring health records.

 Verification and Validation of new proposed architecture.

 Analysis of existing architecture and its drawbacks.

 Propose a new architecture and how it will overcome the drawback of existing one.

6. Plan of Work and Methodology:

Figure below illustrates the proposed system architecture for developing and deploying the
healthcare applications that utilize Cloud Computing. The main components of a Cloud
Computing Service usually are the platform frontend interface that communicates directly with
users and allows the management of the storage content. The interface can be a web client or a
standalone application. The Cloud Storage Facilities manages the physical infrastructure (e.g.,
storage elements) and is also responsible for performing maintaining operations (e.g., backing up
data, etc.) The Cloud Platform interface is also connected to the Cloud Service module, which
handles and queues user requests. Finally, the Cloud Infrastructure module manages user
account, accessibility and billing issues.

Previous work by authors has demonstrated the applicability of mobile devices into retrieving
medical image data from remote repositories wirelessly utilizing proper content coding (i.e.,
wavelet compression with region of interest support). This work has been now extended to
include the functionality of communicating with Cloud Computing platforms and support
communication through Web Services. In this context, Health Cloud has been developed based
on Google’s Android mobile Operating System(OS) using the appropriate software development
kit (sdk). Android is a mobile operating system running on the Linux kernel. Several mobile
device vendors already support it. The platform is adaptable to larger and traditional smart phone
layouts and supports a variety of connectivity technologies (CDMA, EV-DO, UMTS, Bluetooth,
and Wi-Fi). It supports a great variety of audio, video and still image format, making it suitable
for displaying medical content. Finally, it supports native multi-touch technology, which allows
better manipulation of medical images and generally increases the application’s usability. The
Cloud Service client running on Android OS consists of several modules. The Patient Health
Record application acquires and displays patient records stored into the cloud. The Medical
Imaging module is responsible for displaying medical images on the device

It decodes images in DICOM format displaying both image and heard information data. When
JEPG2000 compression is used, the appropriate sub-module decodes the image. The
communication with the Cloud is performed through an implementation of Web Services REST
API that is supported natively by Android. The inherent interoperability that comes with using
vendor, platform, and language independent XML technologies and the ubiquitous HTTP as a
transport mean that any application can communicate with any other application using Web
services.

Data in Cloud are seamlessly stored and presented to the user as if they reside locally. This
means that the Cloud repository is presented as a virtual folder and does not provide the features
of a database scheme. In order to provide the user with data querying functionality, medical
records and related data (images and biosignals) are stored into a SQLite file. SQLite is the
database platform supported by Android. The file resides into a specific location at the Cloud and
is retrieved on the device every time user needs to query data. The query is performed locally
and the actual location of the data in the cloud is revealed to the applications. The database file is
updated and uploaded into the Cloud every time user modifies data, respectively.

UTILIZING AMAZON S3 CLOUD SERVICE

For the realization of the mobile healthcare information management system the Amazon Simple
Storage Service (S3) has been utilized. The main reason for selecting the specific Cloud
Computing platform is that it is a commercial service well established and used successfully in
several applications. It provides users with several interoperable web interfaces for managing
data (SaaS model) and developers with the ability to create their own applications for accessing
the latter (PaaS model) and is suitable for managing healthcare information .

My plan of work includes how IT will play a major role in the improvement and betterment of
health policies in the state it involves to investigate secondary data obtained from HLFPPT and
to analyze the main reasons of failure of improvement of women’s health conditions in Uttar
Pradesh. The plan includes collection of relevant data and application of appropriate tools like
ANOVA to find out the major drawbacks of health management systems

The Core Concept

The basic concept is collecting bio-metric data of target beneficiaries and then linking it with
service provision and MIS. This electronic health record will be stored in a cloud and will be
accessible from anywhere in the world. It will give continuity to health records and obviate the
need for multiple health records and registers. This will also facilitate tracking and validated
service delivery. The validated service delivery will be ensured through bio-markers at the time
of service delivery. For example, at each service delivery point, e.g. at the time of ANC the
woman or beneficiary will attest the receipt of the service by putting her thumb impression on
finger print reader on the device provided to the service provider. It is proposed that, just like in
the case of online examinations, the due lists will be pushed on specific dates (MCHN day) so
that the service provider will be forced to deliver the services to specified beneficiaries on
specified dates. It will also help track performance of the service providers.

Already, under the free drug scheme, all disbursement of medicines is computerized; it is
proposed that all diagnosis and test results too, be recorded in digital form. This will help update
health record of each individual. The health record of an individual will only be accessible by
authorized medical personnel or the individual himself.
Specifically, it will involve following activities:
 a. Each newly registered pregnant woman will be given a unique identification number .
These records will be used for identification and tracking of children, adolescent girls
and pregnant and lactating women for weight, height, MUAC, micronutrient
deficiencies and BMI under nutrition and pregnancies, births and use of
contraceptives under family planning and tracking births, marriages and maternal and
infant/child deaths

b. The real-time collection, storage and transmission of data will reduce errors in data
entry and data manipulation at later stage.

Cloud computing is a new technology and have good performance in storing and accessing
information. Our research mainly focus on the implementation of GAE as a SaaS cloud
computing technique to share healthcare information. With the designed prototype, we could
cover the current interoperability gap in e-health. There are many strengths to use GAE based
SaaS service to solve the problem such as quick development, high availability, large data table
storage, application as web service and authorized information A Computer software will be
designed for online report generation based on handheld computer device (Tablet) based tracking
of women, children and adolescents.

All medical and health information (data) for mother and child will be stored in a ‘cloud’ which
will be accessible at all referral centers through internet.

7.Key Activities and Processes

A. Review of Literature for finding the drawbacks in healthcare in cloud.

B. Problem identification.
C. Evaluation of existing system based on current cloud computing technology.
D. Development of new improved system with proper justification.
E. Collection of Data and analyze it for Improvement.

References, Bibliography, Webliography

[1] IBM and Active Health Management,” Active Health and IBM Pioneer Cloud Computing
Approach to Help Doctors Deliver High Quality, Cost Effective Patient Care”. September 1st,
2011.
[2] Acmen Solution,” Acumen nabs ONC cloud computing:acumen-nabs-onc-cloud-
computingcontract& division”, June 27, 2012
[3] Sabine Koch, Maria Hägglund, Isabella Scandurra, Dennis Moström, “Towards a virtual
health record for mobile home care of elderly citizens”, presented in MEDINFO 2004,
Amsterdam, 2004.
[4] Alvin T.S. Chan, “WWW_ smart card: towards a mobile health care management system”,
International Journal of Medical Informatics vol. 57, 2000.
[5] IBM and ActiveHealth Management. ActiveHealth and IBM Pioneer Cloud Computing Approach to
Help Doctors Deliver High Quality, Cost Effective Patient Care. http://www-
03.ibm.com/press/us/en/pressrelease/32267.wss. Accessed onSeptember 1st,2011.
[6] Khawar Hameed, “The application of mobile computing and technology to health care
services”, Telematics and Informatics, vol.20, 2003.
[7] Eneida A. Mendonça, Elizabeth S. Chen, Peter D. Stetson, Lawrence K. McKnight, Jianbo
Lei, James J. Cimino, “Approach to mobile information and communication for health care”,
International Journal of Medical Informatics, vol 73, 2004.
[8] Maglogiannis I., Doukas C., Kormentzas G., Pliakas T., "Wavelet- Based Compression With
ROI Coding Support for Mobile Access to DICOM Images Over Heterogeneous Radio
Networks", IEEE Transactions on Information Technology in Biomedicine, vol.13, July 2009.
[8]National Rural Health Mission (NRHM). National Rural Health Mission. Framework for
Implementation 2005-2012. Ministry of Health and Family Welfare, Government of India.
[9]Government of India (GoI) (2008). “Bulletin on Rural Health Statistics in India: March
2008.”
[10]Indian Public Health Standards (IPHS) for Community Health Centre. March (2006). Draft
Guidelines. Directorate General of Health Services, Ministry of Health & Family Welfare,
Government of India. Available at http://www.mohfw.nic.in/NRHM/Documents/
IPHS_for_CHC.pdf.
[11] Gottlieb, L. K et ai, "Regulatory and policy barriers to effective clinical data exchange:
Lessons learned from medslnfoED". Health Aflairs,2005
[12]PFI-Population Foundation of India (PFI) is a national non-government organization at the
forefront of policy advocacy and research on population issues in the country.
[13] Charalampos Doukas, P. Thomas Pliakas, and Maglogian I.,” Mobile Healthcare
Information Management utilizing Cloud Computing and Android OS”
[14] Van Hu, Lu F., Khan I, Bai G,” A Cloud Computing Solution for Sharing Healthcare
Information”, School of Computing Blekinge Institute of Technology Karlskrona.