MEETING ROOM – a Secure Multi-Access, Cross-Platform Telemedicine Application

Geck Keat Chan, Tan Kok Kiong, Arun Shankar Narayanan Department of Electrical and Computer Engineering

National University of Singapore Singapore

Abstract—The high costs and inconvenience of visiting a doctor for medical advice have deterred a sizable number of elderly and needy from seeking proper medical treatment promptly and this may cause their conditions to deteriorate and possibly resulting in a more severe impact on their daily lives. Thus, this application is designed with the aim to bring more convenience and health care services to these less privileged segments of the community. In this paper a secure multi-access cross-platform telemedicine application, known as MEETING ROOM, has been designed and developed to provide easily accessible health care services. The MEETING ROOM application adopts a web-based approach in general to provide the flexibility to run on cross-platform devices. Computing devices with network connectivity can be placed in clinics, day care centers, community centers or right at their homes so that they can easily access the application with those devices. It is a hybrid application, comprising of a web portal and a video conferencing application. The web portal is used to manage the system and the users in a secure manner while the video conferencing application provides a convenient communication platform for the patients to consult a doctor on their conditions and for the doctors to hold online meetings. A web-based version and mobile Android version of the video conferencing application are developed to provide the flexibility.

Keywords—telemedicine; teleconference; web-based application

I. INTRODUCTION Over the years, technology has flourished for the benefit of

mankind. It has brought about more convenience, connection, productivity and easier communication. While modern technology has greatly improved people's lives through different fields such as work, education and industry, there is minimal effort in using technology to improve health care. Today, many people still have to make a visit to the clinic personally to seek medical advice from the doctors or specialists. This brings about much inconvenience, especially to the elderly patients. Besides, there are many cases where seeking medical advice from doctors personally may be deemed as unnecessary and costly. Examples include rehabilitation  treatment  for  osteoporosis,  arthritis,  Alzheimer’s  disease and sensory impairments [1].

Making quality and low cost medical services accessible to all has always been a challenging goal among the health care providers due to the universal problem of limited resources on both medical personnel and equipment [2]. To help patients reduce the health care costs and the non-critical visits to the

clinics or hospitals, health care professionals can provide remote health care services with the help of telemedicine. From its beginning, telemedicine has been used in a variety of health care fields and is often used by off-site health care professionals to provide consultant services and sometimes remote medical diagnosis or treatment to those on the scene. These diagnosis and treatment can be done at a great distance through methods such as video conferencing or rapid transmission of digital files.

With the development of more sophisticated technology, telemedicine is a discipline that is gaining widespread interest among the health care providers. The rising interest in telemedicine is also being driven in part by the proliferation of portable and affordable computing devices, and the development of international telecommunications standards [3]. Statistics reported by International Telecommunication Union in the ICT Facts and Figures Report 2013 have shown an increase in the number of internet users and mobile broadband  subscriptions.  Currently,  almost  40%  of  the  world’s  population is online. It is also expected that the number of mobile broadband subscriptions will exceed 2 billion worldwide by the end of 2013 [5]. With appropriate technologies and the widespread use of Internet, it is conceivable that telemedicine has the potential to provide the underserved communities with easy access to quality and lower cost health care services.

II. OBJECTIVES With frugal engineering, a philosophical approach to

designing products for customers with low purchasing power, this work aims to design and develop a cost-effective and easy-to-use telemedicine system to provide easily accessible and lower cost health care services for the elderly and the needy in the community.

With the proliferation of portable and affordable computing devices such as tablets and smart phones, this telemedicine system will provide a web-based solution that allows for the flexibility and portability to run on cross-platform devices. Computing devices with network connectivity can be placed in clinics,   hospitals,   day   care   centers,   old   folk’s   homes,  community centers and even right at the individuals’ homes so that the elderly and the needy can easily access the system with those devices. They can make use of the devices to do simple health assessment on their own or with the help of health care personnel and their results will be saved in the system for the

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Fig. 1. Use-case diagram for Administrator

Fig. 2. Use-case diagram for Doctor

doctors to access and diagnose; after which, the patient can have a remote online audio-visual consultation with a doctor via this system.

Besides, another objective of the work depicted in this paper is to bring about convenience to the doctors by providing a communication platform for two or more doctors to discuss patients’   conditions   over   remote   online  meetings.  To   achieve  this aim, the video conferencing application for this system is required to adopt a secure multi-access approach. Therefore, the work to be described in the paper is done with an ultimate aim of using the modern technologies to help make long-term health care costs more affordable especially for the elderly and the needy in the society as well as to bring about more convenience to them while seeking medical treatment.

III. PROPOSED SOLUTION Although the technologies relating to video conferencing

and health information management are readily available, they are not well applied to telemedicine. This paper thus proposes a solution that taps into the potential of the related technologies to make health care services more accessible and affordable through telemedicine.

To satisfy the requirement on easy accessibility to the telemedicine system on computing devices such as desktops, laptops and mobile devices, a web-based approach is adopted in general as a web-based system can be easily accessible through the web browsers running on any device. Thus, for this proposed solution to work, the underlying assumption would be that there must be network connectivity in the area of usage as well as on the devices used.

There are three main target users of this system. They are the patient, the doctor and the administrator, who will be responsible for managing the system and the users. The proposed system is known as the MEETING ROOM, which consists of a web portal and a video conferencing application.

The main feature of the system is the video conferencing application. As the name of the application – MEETING ROOM implies, this application simulates the concept of a meeting held in a room in real-life, where multiple authorized parties are involved.

Before the patient or the doctor can utilize the video conferencing application for consultation or for meeting, they will have to request permission to access a room via the administrator. The patient will have to approach the administrator to book a consultation slot with a doctor. The administrator  will  have  access  to  the  doctor’s  schedule  to  create  a match. After which, both the patient and the doctor will be granted access to the selected meeting room on a specific date and time slot. Similarly, when doctors would like to utilize the MEETING ROOM application for a meeting, they would have to approach the administrator to grant them access to a room at their desired time slot. In this way, the video conferencing application in MEETING ROOM can support secure multi-access where only authorized users can participate in a multi-party consultation or meeting.

The MEETING ROOM application is a hybrid application, a mixed breed [6] made partially from web components, and partially from native components. They can run on the web and on the mobile device. The video conferencing application in MEETING ROOM can be accessed via a web browser on a computer with the Adobe Flash Player plug-in. As the access to camera is not supported on mobile web browsers, and in order to allow for the flexibility and portability to run on mobile devices, the video conferencing application is repackaged to a mobile application that is compatible for running on mobile Android devices with the Adobe AIR (Adobe Integrated Runtime). Both the web-based version and the mobile Android version utilize an Adobe Flash Media Server for video and audio streaming between the users involved in the video conferencing. To reduce the bandwidth in streaming the videos, the H.264 codec, which is supported by Adobe products, is used in encoding and decoding the video streams. The video conferencing application will also communicate with a backend server running the database management system.

Apart from the video conferencing feature, the proposed system also provides a web portal which allows the administrator and the doctors to access and manage the data records in the system. Fig. 1 and Fig. 2 show the use-case diagram for the administrator and the doctor on what they can do on the web portal respectively.

IV. SYSTEM ARCHITECTURE The proposed telemedicine system is a distributed, yet

connected one. As shown in Fig. 3, the proposed system utilizes the client-server architecture in which a central server deployed will accept incoming connections and the clients will be able to establish connections and communicate through this server. The architecture consists of five components: patient, doctor, administrator, a web server with a central database and a streaming media server for facilitating video conferencing. With the intention for the system to be accessible on cross-platform devices, the system is designed to run on the

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Fig. 3. Client-Server system architecture

Fig. 4. Video streaming between client and server

ubiquitous internet network. The web server hosts all the web pages of the web portal and serves them to the clients upon receiving their Hypertext Transfer Protocol (HTTP) requests. The internet provides the access for users to connect to the server and the central database to view and manage the data records in the database.

In addition, the video conferencing application in MEETING ROOM also employs the internet as a communication channel, where both the doctor and the patient connect to a streaming media server and the server facilitates the connection and communication between them. Client-server architecture is adopted in this video conferencing application to support multi-party video conferencing.

The system used is an Intel i5 processor with 8 GB RAM (Random Access Memory) running windows 7 on a 64 bit Operating System. Further, the server machine must have a network connection and a network interface card that is configured with a static IP (Internet Protocol) address associated with a particular hostname so that users can connect to this server and access the web pages in the telemedicine system by simply entering its URL (Uniform Resource Locator) into a web browser. Server is on an open connection that allows both incoming and outgoing TCP (Transmission Control Protocol) connections by having the TCP ports 80 and 1935 unblocked for web server and streaming media server respectively.

A web server is set up by installing web server software that handles HTTP requests from clients. The web server software is a program that will listen on TCP port 80 for any HTTP requests and return HTTP responses to these requests accordingly. The open-source web server software, Apache HTTP Server 2.2 is installed on the server machine. Apache HTTP Server software is used because it is open-source and it is the most popular HTTP server software, handling more than half of all websites in existence today serving 54.98% of all active websites [7]. Besides hosting and serving web pages, the server machine also serves as central database storage by running the open-source relational database management system software, MySQL. This is a popular open-source database, which garners more than 11 million active installations worldwide [8].

Further, the video conferencing application requires the use of a streaming media server to facilitate video and audio communication between the clients connected to a room in the application. In this system, Adobe Flash Media Development Server 4.5 is installed on the server machine. Most streaming media server software including Adobe Media Server requires proprietary licenses. There is a free but limited version of Adobe Flash Media Development Server 4.5 but with this version, the number of simultaneous connections to the server is limited to ten, which is used here.

V. IMPLEMENTATION

A. Database Setup The purpose of having a database is to store the personal

data   of   the   users,   the   patients’   medical   test   results   and  consultation records and most importantly, to keep track of the usage of the video conferencing application.

B. Web Portal The web portal is an integral part of the MEETING ROOM

application. It provides a web-based platform for the administrator and the doctors to access and manage the data records in the system. The web portal is implemented using the server-side scripting language PHP 5.0.

C. Video Conferencing Application The other feature in the MEETING ROOM is the video

conferencing application. This section will elaborate on the implementation of the video conferencing application as well as the multi-access approach used, how cross-platform is achieved and also on how users are authenticated to ensure secure multi-access of the video conferencing application.

1. Constituent Technologies

The video conferencing application, accessible via the web browser on desktops or laptops, is developed based on the Adobe Flash Player platform. Adobe provides one of the leading online digital media delivery platforms with full support for H.264 encoding and decoding [9].

The video conferencing application makes use of a client-server architecture, where the server and the client communicate over a persistent connection using RTMP (Real-Time Messaging Protocol) as shown in Fig. 4.

2. Cross-Platform Application

Although web applications in general can be accessed on cross-platform devices, there are some limitations to what web apps can do on the devices. One of the limitations would be that web apps  have   restricted  access   to   the  device’s  native  features and hardware such as camera, accelerometer, GPS (Global Positioning System), etc. Thus, the MEETING ROOM application utilizes a hybrid approach by extending the web-based version of the video conferencing application to a mobile Android version.

Building the video conferencing application using Adobe Flash Builder 4.6 and Apache Flex

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Fig. 5. Login panel for web portal

Fig. 6. ‘View  Records’  console

Fig. 7. a) Creating a new patient record b) Making a new booking

Framework 4.5, gives an added advantage of having one single code base that targets multiple platforms. Adobe Flash Builder 4.6 software is designed to help software developers to rapidly develop cross-platform rich internet applications and content using the open source Apache Flex framework. While creating the mobile Android version of the video conferencing application, minimal modification is done to the code used for the web-based version, except for some changes made to the user interface of the application in order to fit the screen resolution of the targeted mobile device.

3. Multi-access Approach

Another feature of the video conferencing application is that it allows multi-party conferencing. Multi-access is implemented by the use of shared object that is created on the flash media server for each meeting room and with the SyncEvent handler of each client handling the dynamic access to the live streams of multiple connected   users   and  playing   them  on   the   client’s  application console.

4. Authentication of User

As the video conferencing application adopts a multi-access approach, it is important to ensure that it is secure to allow multiple users to connect to a meeting room and to protect the privacy of the users in a meeting room. Login details and the processing to be carried out will be sent to the server and processed by the server side PHP script.

D. Security of the System Currently, the system is secured by password login. This

means that when accessing any page on the web portal, a valid login comprising of a username, password and user identity number needs to be supplied and sent to the server for verification. Upon successful verification, the server will create   PHP   session   variables   to   store   the   user’s   identity information. These session variables are used to authenticate the user when the user tries to access any page on the web portal. Session information is stored temporary on the server and will be deleted after the user has left the website.

To secure data transmission between clients and the web server, the Apache HTTP Web Server 2.2 can be configured with SSL/TLS (Secure Socket Layer/ Transport Layer Security) support, using the mod_ssl module [10]. With SSL configured on the web server, it allows the client to communicate with the web server using HTTPS, which encrypts HTTP traffic to provide secure communication over a network.

VI. MAIN RESULTS The web portal in the MEETING ROOM application

provides administrative features that allow the administrator and the doctors to manage the system and its users. Fig. 5 shows the login panel for the web portal. On the web portal, a

useful  resource  is  the  ‘View  Records’  console  as  shown  in  Fig.  6. The types of records that are available on the console include information on patients, doctors, medical test results, and consultations and meeting room access records.

Besides viewing the data records, the administrator can perform create, delete and edit operations on the console to manage the data records. Fig. 7(a) shows adding of new patient record. To book a consultation record, the administrator has to fill up a   form   with   the   patient’s   name   and   NRIC (National Registration Identity Card), select the date, time slot, station ID for the consultation, and submit it for processing on the server as shown in Fig. 7(b).

With control on the usage of the video conferencing application and by keeping track of the duration of usage for each user, a business charging model can be put in place where necessary, including charging based on fixed rate per person, per unit of time spent etc. On the other hand, the doctors will only be able to view and delete some data records but not create or edit any of the data records. They will also be able to submit their diagnosis or review for the patients in the Review textbox  found  on  every  patient’s  consultation  record  as  shown  in Fig. 8. As for the video conferencing application, it provides a communication platform for the patient and the doctor to have remote consultations and for the doctors to have remote meetings. Both the web-based version and the mobile Android version of the video conferencing application are developed.

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Fig. 8. Patient's consultation record

Fig. 9. Video conferencing application

Fig. 10. Interface for selecting meeting room to connect

Fig. 11. Online conferencing among three doctors

The web-based version and the mobile Android version of the video conferencing application are as shown in Fig. 9. To access the video conferencing feature on both versions, users are required to enter a valid username and NRIC as registered in the system. After a user successfully logs in, he would be able to select the meeting room to connect. The interface is as shown in Fig. 10 for the web-based and mobile Android versions.

The doctor-patient consultation simulation was tested and another simulation was conducted whereby multiple doctors were present in a conference session. The window on a desktop PC is as shown in Fig. 11. The same simulation was conducted using an Android phone and the results are the same for one-to-one sessions, but not able to perform a multi-party conference due to the limited hardware resources in mobile devices.

VII. EXPERIMENTAL EVALUATION

The main objective of the performance evaluation is to make use of the results obtained to help determine the appropriate number of users who can connect to a meeting room. The results obtained can also aid the administrator in planning the meeting room usage. The parameters evaluated are the CPU (Central Processing Unit) usage, Network usage and RAM Usage. These parameters will be evaluated by varying the number of connections to a meeting room from 0 to 3 connections using Windows Performance Monitor. Further, the Network usage parameter is also measured by capturing the packets on a server for about 3 minutes and the packets are analyzed and filtered with Wireshark [11].

The simulations are performed in a local area network environment with clients running the web-based version of the video conferencing application on desktops. Table I shows the simulation results obtained for the different number of connections to a meeting room.

TABLE I SIMULATION RESULTS OBTAINED FOR DIFFERENT NUMBER OF CONNECTIONS

Number of Connections

CPU Usage (%)

RAM Usage (%)

Network Usage

(Mbps)

Network Usage (Wireshark)

(Mbps) 0 1 - 2 31 0 0 1 2 - 3 31 ~ 1 0.906 2 4 - 5 32 ~ 4 3.299 3 5 - 6 32 ~ 9 8.365

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Fig. 12. Graph for Network Usages evaluated using Wireshark VS Number of Connections

Fig. 13. Number of live streams uploaded to and downloaded from a server

The results obtained show that as the number of connections increases, the CPU usage increases linearly and the RAM usage remains approximately constant. As for the Network usage, both the Performance Monitor and Wireshark produce similar results. It is observed that the Network usage increases exponentially as the number of connections to a meeting room increases as shown in Fig.12. This is because for each increase in the number of connections, the number of live streams uploaded to the server increases by one and the number of live streams sent out to the clients will be N*(N-1) where N represents the number of connections to a meeting room. Fig. 13 illustrates the number of live streams received by the server and sent out from the server for the case of 1 to 4 connections.

VIII. CONCLUSION In this paper, the design of a secure multi-access, cross-

platform telemedicine application is presented. The MEETING ROOM application consists of a web portal and a video conferencing application.

Unlike the video conferencing software available off the shelves, the video conferencing application developed here has included features that allow for secure multi-access where multiple authorized parties can participate in a video conferencing session. This helps to bring about convenience to patients and doctors as they can have online consultations and meetings via the MEETING ROOM application rather than having to meet each other personally.

With both web and native technologies, a telemedicine system has been successfully implemented which is easily accessible on cross-platform devices such as computers and smart phones that have network connectivity. This helps to improve the reach of health care services to the underserved communities globally.

There is still room for further improvement. Currently, the mobile Android version of the video conferencing application has the limitation that the mobile user can only receive and view a single video stream from the main transmitting party. This is mainly due to the limited hardware resources available on mobile devices. With higher speed and more efficient processors designed for mobile devices, the mobile Android version of the video conferencing application would be able to perform a multi-party video conferencing.

In summary, the MEETING ROOM application integrates the   capabilities   of   accessing   patients’   data   and   video  conferencing in one system and thus differs from the existing telemedicine  systems  where  access  to  patients’  data  and  video  conferencing capabilities are provided as two separate systems. Further, this system maximizes the use of resources that are free and open-sourced. This helps to reduce the cost of having such a system, which in turn makes health care costs affordable for financially challenged patients.

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