ORIGINAL PAPER

A Cloud System for Mobile Medical Services of TraditionalChinese Medicine

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

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

Abstract Many medical centers in Taiwan have started toprovide Traditional Chinese Medicine (TCM) services forhospitalized patients. Due to the complexity of TCMmodalityand the increasing need for providing TCM services for pa-tients in different wards at distantly separate locations withinthe hospital, it is getting difficult to manage the situation in thetraditional way. A computerized system with mobile abilitycan therefore provide a practical solution to the challengepresented. The study tries to develop a cloud system equippedwith mobile devices to integrate electronic medical records,facilitate communication between medical workers, and im-prove the quality of TCM services for the hospitalized patientsin a medical center. The system developed in the study in-cludes mobile devices carrying Android operation system anda PC as a cloud server. All the devices use the same TCMmanagement system developed by the study. A website ofdatabase is set up for information sharing. The cloud systemallows users to access and update patients medical informa-tion, which is of great help to medical workers for verifyingpatients identification and giving proper treatments to pa-tients. The information then can be wirelessly transmitted

between medical personnel through the cloud system. Severalquantitative and qualitative evaluation indexes are developedto measure the effectiveness of the cloud system on the qualityof the TCM service. The cloud system is tested and verifiedbased on a sample of hospitalized patients receiving the acu-puncture treatment at the Lukang Branch of Changhua Chris-tian Hospital (CCH) in Taiwan. The result shows a greatimprovement in operating efficiency of the TCM service inthat a significant saving in labor time can be attributable to thecloud system. In addition, the cloud system makes it easy toconfirm patients identity through taking a picture of thepatient upon receiving any medical treatment. The result alsoshows that the cloud system achieves significant improvementin the acupuncture treatment. All the acupuncture needles nowcan be removed at the time they are expected to be removed.Furthermore, through the cloud system, medical workers canaccess and update patients medical information on-site,which provides a means of effective communication betweenmedical workers. These functions allow us to make the mostuse of the portability feature of the acupuncture service. Theresult shows that the contribution made by the cloud system tothe TCM service is multi-dimensional: cost-effective,environment-protective, performance-enhancing etc. Devel-oping and implementing such a cloud system for the TCMservice in Taiwan symbolizes a pioneering effort. We believethat the work we have done here can serve as a stepping-stonetoward advancing the TCM service quality in the future.

Keywords A cloud system . Traditional ChineseMedicine .

Mobile devices . Electronicmedical records

Background

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

Nian-Ze Hu and Chia-Ying Lee contributed equally to this study andshare first authorship.

N.

hospitalized patients [1]. Doctors of TCM have provideddiverse TCM treatments such as acupuncture, moxibustion,and herbal remedies. Among these services, acupuncture haslong been attracting strong attention from the public. Thepopularity comes not only from its amazing curing powerbut also from its portability. Unlike other Western medicalservices such as X-rays and gastrocopy for which patientsmust be gathered to a designated place for these medicalexaminations, acupuncture treatments can be given right atthe place where patients are hospitalized. In particular, this on-site treatment feature is of vital importance to patients who arenot able to move around by their own, e.g., elderly nursinghome patients and physiotherapy patients. The increasingdemand for TCM services from patients in various wardsscattering around the hospital, along with the complexity ofTCM modality, has made it harder to manage the situationmanually without making any careless mistakes. Suchlikenegligence sometimes may be health-threatening for patients.The traditional electronic anamnesis system along with thepaper-based recording system has become insufficient to as-sure high-quality TCM services. Under the traditional system,health care workers need to jot down information on theirpatients and then input what they have gathered to the elec-tronic anamnesis system. Such inextricable and repetitivework tends to not only make the records fallible due to humanerror but also expend excessive labor resources that otherwisecan be saved.

Under the current TCM practice in Taiwan, very few TCMdepartments have wards exclusive to their hospitalized pa-tients [2]. Consequently, hospitalized TCM patients are mostlikely to be admitted to whichever ward has free beds. Due tofactors such as the scattering of hospitalized TCM patients, thenature of the TCMmedical service, and the limited number ofmedical staff, doctors and nurses have to go around to differ-ent wards so that they may not cooperatively provide servicesto the same patient at the same time. For example, doctors firstcarry out the acupuncture treatment and nurses then need toremove the needles in patients after a certain period of time.The traditional pen-paper-electronic anamnesis system doesnot allow these medical staff to share patientsmedical servicerecords in a timely manner, which may further cause a wasteof time due to repeated interrogation and enquiry. This alsodemonstrates that integrating patients medical informationfrom various sources and facilitating the exchange of thegathered information become extremely important.

Even if TCM departments can have their own wards clus-tering together in a designated area, the traditional pen-paper-electronic anamnesis system still cannot do the job. There hasbeen a rising trend toward information digitization for medicalinstitutions [3]. The TCM is thus no exception. Furthermore,electronic medical records not only can provide instant accessto and update on client information but also can expedite theexchange of medical image information between hospitals [4].

For example, a cloud-based emergency health care informa-tion service system has been used in India to provide on-siteretrieval of patients past medical records [5]. Following theglobal trend, a number of hospitals in Taiwan have started tobuild cloud computing electronic health systems for theirwestern medicine services. In addition, a real-time mobilenursing information system has also been developed for eval-uating patients conditions [6]. In contrast, there has had nosimilar development for the TCM service. In order to catch upwith the trend and hence provide high-quality TCM services, acloud computing system customized for the TCM service ismuch needed.

According to the National Institute of Standards and Tech-nology of the USA, Cloud Computing is defined as amodel for enabling convenient, on-demand network accessto a shared group of configurable computing resources (e.g.,networks, servers, storage, applications, and services) that canbe rapidly provisioned and released with minimal manage-ment effort or service provider interaction [7]. In short, thecloud system for mobile medical services is aimed to apply thecloud computing method to medical affairs [8]. The cloudcomputing system provides a new way to solve problemswith the medical service. Some studies have recently beenconducted regarding how to implement the cloud frameworkin medical affairs [8, 9].

A cloud system for mobile medical services is expected tomake it easier for doctors and nurses from wards at differentlocations to access real-time medical records of patients [10].It is intended to bring together information from disparatesources such as electronic anamnesis records and medicationrecords, and thus provide ubiquitous access for those whoneed the information during a patients hospitalized course.Integrating patientsmedical records to assure low-cost, high-quality health care service, however, requires cooperation andcoordination [11]. If widespread support from various groupsof the organization is attainable, the cloud system for mobilemedical services can enhance the accuracy and efficiency ofhospital information systems.

This study is to demonstrate how a cloud system withmobile devices can improve the quality of the TCM service.In particular, we place an exclusive emphasis on how thecloud system can help enhance the effectiveness of the acu-puncture treatment. The reasons for the choice are three-fold.First, the acupuncture treatment has long been the archetype ofthe TCM service. Second, acupuncture has also been growingin popularity. There has been an increasing demand for acu-puncture as a complement of or adjunct to other medicaltherapies for treating diseases such as cancer, stroke, andchronic diseases. Therefore, assuring patients of high-qualityacupuncture treatments has been given top priority. Third, theintricacies of the acupuncture treatment can further underlinethe need for a cloud system and the contribution the systemcan make to the effectiveness of the acupuncture treatment.

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Materials and methods

Setting

The regular TCM service at the Lukang Branch is currentlyoffered at three distantly separate places in the hospitals mainbuilding: the physiotherapy center on the first floor, the out-patient clinic on the second floor, and the nursing center on theeleventh floor. During a 3-h outpatient clinic session, a phy-sician and a nurse, along with either of an intern or a resident,are in charge of the TCM service.

Outpatients receive the TCM service in the outpatient clinicroom. Therefore, medical data of these patients can be rela-tively easily accessed and updated through the computersystem around in the clinic room. However, the situation getsa bit complicated when doctors give the TCM (particularly,acupuncture) service to patients at the physiotherapy and thenursing centers. Doctors must visit these two centers to pro-vide the acupuncture service. Before making such a visit,doctors need to review the patients medical records, writedown key information, and bring the written note with them.They then need to jot down their diagnoses and treatments onthe patients. Finally, they bring these new medical notes backto their clinic office (or to the nearest laptops and PCs withaccess to the anamnesis system) and key in the medical notes.Therefore, a bit more efforts are needed for providing theacupuncture service to patients outside the outpatient clinicroom.

Normally, breaks are prearranged during the 3-h course ofthe outpatient clinic service so that the TCM physician and theresident are able to visit the physiotherapy and the nursingcenters, and give TCM treatments to their patients duringthese breaks. In addition to the normally scheduled visits,there may be unplanned visits to the physiotherapy and thenursing centers for providing the TCM service to late-arrivalpatients or new patients. This would cause an even hecticschedule for the medical staff. Furthermore, the travel betweenthe physiotherapy center on the first floor and the outpatientclinic room on the second floor takes the doctors some addi-tional time.

Table 1 reports summary statistics of the average number ofpatients, the treatment time per patient, the travel time pervisit, and the data processing time across the three placeswhere the TCM service is provided during the 3-h session.

Details are described below. The TCM medical staff start the3-h service session in the outpatient clinic. The physicianconducts a routine inquiry on the health condition of thepatient and makes a comprehensive diagnosis. At the sametime, the physician or the resident writes down the diagnosisresult and gives the acupuncture treatment to the patient whennecessary. When an acupuncture treatment is given, any of thephysician, the resident, and the nurse need hand-write downdetails of the acupuncture treatment including the number andthe location of the acupuncture needles that are inserted intothe skin. In general, the nurse is responsible for removing theneedles based on the hand-written records. These writtennotes are time-consuming, which, coupled with the large totalnumber of patients the physician needs to treat during the 3-hsession, may lead to a situation where the acupuncture treat-ment is done but details of the treatment have not been jotteddown. Furthermore, under a time constraint, doctors some-times cannot record all the details of the acupuncture treat-ment. Under such circumstances, details of the acupuncturetreatment may be mis-communicated between health careworkers, and the nurse with no complete guidance from thephysician can only remove those needles that can be spotted.There is then always risk that some needles are inadvertentlyleft un-removed. In certain cases, this may endanger thepatients health.

The physician, the resident, and the nurse need also visitthe nursing room on the eighth floor and the physiotherapycenter on the first floor during the 3-h session. Only some ofthe patients receiving physiotherapy treatments and/or nursingservices need the TCM service, in particular the acupuncturetreatment. Most of these TCM patients, mainly previouslyreferred to the TCM department by non-TCM doctors, mayreceive the Western Medicine treatment and the TCM treat-ment at the same time. Mostly, the physician gives a dynamicacupuncture treatment to these patients, under which patientscan still move around as they like to. This is in contrast to theusual acupuncture treatment, under which patients need tokeep still.

Like physiotherapy patients, most nursing patients are re-peat patients but first-time patients emerge occasionally. Fur-thermore, some of the physiotherapy patients and most of thenursing patients here are not able to move on their own so thaton-site diagnoses and treatments are necessary. These on-siteservices emphasize the need for a more effective system that

Table 1 Estimates of time spentin the acupuncture treatmentat various locations

Locations Acupuncturetreatment timeper patient

Additionaldata-processingtime in a 3-h session

Travel timeper visit

The averagetotal numberof patients

Physiotherapy center 10~20 min 10 3 min 5 patients

Outpatient clinic 10~20 min None None 8 patients

Nursing center 10~20 min 24 5 min 12 patients

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can improve communication of medical information betweenmembers of the medical staff.

The cloud system for mobile TCM service

The proposed TCM cloud system is composed of four medicaldatabases: a database of patients identification data (e.g.,personal ID number, hospital ID number, personal photos andother background information), a database of patients TCMmedical records that is linked to the database of the patientswestern-medicine medical records, a database of laboratory testresults, and a database of acupuncture points. Among thesefour databases, the acupoint database is of particular interest.The acupoint database serves as a supporting device for pro-viding doctors with helpful acupuncture tips. It is well knownin the traditional Chinese medicine that energy flows throughregular channels to different acupoints. Certain networks ofregular channels and particular sets of related acupoints mustbe taken care of when the acupuncture treatment is given topatients with a specific disease. The database collects numeroussets of regular channels and acupuncture points so that doctorscan easily specify the acupoints into which acupuncture needleswill be pushed when they are trying to cure their patients of agiven disease. It also collects a priority list of acupoints, whichcan provide useful guides to TCM doctors for performing theacupuncture service. Besides, doctors can customize the data-base by storing their personal secret recipes for treating variouskinds of disease. The acupoint database can hence expedite theacupuncture treatment and at the same time improve the qualityof the acupuncture treatment.

The medical staff can access these databases through var-ious wireless network devices such as personal computers,laptops, PDA, and Pad. The structure of the system is depictedin Fig. 1, and the equipment architecture is showed in Fig. 2.The cloud system integrates mobile app with several back-endservers. In order to build up a SaaS-like infrastructure, ourdatabase server and application server are virtually hosted inone standalone server. All data can be accessed through webservices provided by an application server while the datatransmission process is secured against outside parties. Fur-thermore, the mobile app is designed by HTML5 and jQuerytechniques so that it can be executed on any devices such asiOS, Android, etc.

System design and deployment

The proposed cloud system has three tiers: the back-end tier,the application tier and the client tier. Cloud database serversare located in the back-end tier, which sets up the user-authentication and policy-authorization mechanisms for allqueries. The application tier hosts the web services that canbe invoked by clients to retrieve the intended records fromcloud database servers. Finally, there are two types of clients

in the client tier: mobile devices and analytical clients. Datastored in the cloud database server can be accessed via mobiledevices. However, when further analysis, such as statisticalanalyses and summary reports, on the retrieved data is needed,analytical clients must play the role in doing the job.

The system flow

The mobile system The activities involved in the mobile sys-tem are depicted in Fig. 3. It focuses mainly on how to enhancethe quality of the TCM acupuncture service. First, through themobile system, doctors can review a patients anamnesis andinput the diagnosis results. Based on these records, doctorsdecide whether the patient needs the acupuncture treatment.Second, when the doctor decides to give the patient the acu-puncture treatment, she/he can use this database to get helpfultips for performing the acupuncture treatment. Through themobile system, doctors can record the details of the treatmentincluding the acupuncture points, the number of needles pushedinto the patients skin, and the starting time and the time span ofthe treatment for even every acupuncture needle. When thetreatment is done, the system will then warn the person incharge (e.g., the nurse) to remove the needles and require theperson to confirm that all the acupuncture needles are removed.Since the time each acupunctural needle must stay stuck intothe skin may vary even in a specific acupunctural treatment, thecloud system enables the medical staff to remove each needleprecisely at the time when it is needed to be removed. This willensure not only that all the needles can be punctually handledbut also that medical negligence can be greatly reduced, signif-icantly enhancing the quality of the treatment. Finally, doctorscan write prescriptions for their patients on-site. Completerecords can be transmitted back to the TCM cloud databasethrough automatically synchronized mechanisms.

The back-end system Although the back-end system cannotperform on-site medical services in relation to the mobilesystem, it is in fact indispensable to the cloud system of theTCM service. The back-end system still has its competitiveedge in the cloud system. The system is established throughweb interfaces so that users can easily retrieve, manipulate, andstore data via personal computers and laptops. In addition, morethan what the mobile system can do, the back-end system iscapable of doing analytical work through its links with statisti-cal tools. To conserve space, we here present only two types ofthe activity flow based on the back-end system. Figure 4 depictshow the back-end system manages patients medical records.Figure 5 shows how the acupoint database is maintained.

System structure

The mobile system The structure of the mobile system isshown in Fig. 6. The system is structured so that it can perform

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three main functions. The first function is to assist the medicalstaff in making on-site diagnosis and giving proper on-site(acupuncture) treatments to patients. The function is of pri-mary importance since portability is a characteristic feature ofacupuncture. We view this function as the most importantcontribution our cloud system makes to the TCM service.The mobile system is also structured to have the function ofcalculating Barthel index, which is intended to measure thehealth status of a stroke patient. The reason for incorporating

such a function into the mobile system is that acupuncture hasbeen widely used to cure the disabled. Since these patients areusually unable to move around by their own, on-site medicalservices are especially needed. This also explains why theTCM doctor in charge of a 3-h outpatient clinic needs to giveon-site acupuncture treatments to patients in the physiotherapycenter and the nursing room, where most of the disabledpatients are hospitalized. An in-time Barthel index measurebecomes important for doctors to evaluate the effectiveness of

Patients medical records

Traditional Chinese Four-

diagnosis records

Personal photos and medical imaging

Laboratory data

PDA

Pad Laptop

PC

Cloud System DiagramFig. 1 The cloud architecturediagram

Cloud Database Servers

Mobile Devices

IBM x3650Server32GB RAM300GB HD x5 (Raid5)Windows 2008 Server SQL Server 2008

Application Servers

Analytical Clients

IBM x3650Server16GB RAM300GB HD x3 (Raid5)Windows 2008 Server SQL Server 2008

Android3.1 or later 1GB RAM32GB StorageWifi network

Intel i7 PC4GB RAM500GB HDWindows7 Professional

Equipment Architecture Diagram

Fig. 2 The equipmentarchitecture diagram

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the acupuncture treatment on the stroke patient. The thirdfunction provided by the mobile system is data synchroniza-tion, which allows members of the medical staff to share themost current medical data.

The back-end system The back-end is structured mainly tomaintain data of the TCM service (Fig. 7). It however alsoprovides a link with the database of patients western medicalrecords so that doctors can review and retrieve their patientswestern medical records when necessary. With regard to theTCM data maintenance function of the back-end system,doctors can review onWeb browsers patientsmedical recordsincluding Four-diagnosis results, prescriptions written to anyspecific patient, acupuncture treatments given to any specificpatient. The back-end system also provides a specialist

knowledge base to help the TCM medical staff improve thequality of the TCM service. This is done through the follow-ing two mechanisms. The back-end system first assemblesvarious types of acupuncture-related data such as acupointlayouts, regular channel layouts, and acupoint priority listsso that members of the TCM medical staff can make easyreference when they need to. The system then allows users todefine useful configurations such as acupoint sets well-suitedfor particular acupuncture treatments, regular channel sets forparticular purposes, and prescription sets for particular dis-eases. The medical staff can also create their own configura-tions based on their personal experience and knowledge.These helpful tips not only save doctors time in giving theirpatients the acupuncture treatment but also help doctors max-imize the power of the acupuncture.

review the patients' medical records

enter four-diagnosis results

record acupuncture places & numbers

perform regular task

notify to remove needles

notify to remove needles

write prescriptions

finish the treatment

Start

End

need an acupuncture treatment?

time is up?

Fig. 3 The activity diagram ofmobile operations

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An application of cloud computing to the TCM anamnesissystem

The application of cloud computing

We now test and verify the cloud system based on a sample ofhospitalized patients receiving the acupuncture treatment atthe Lukang Branch of Changhua Christian Hospital (CCH) inTaiwan. We propose several measures to evaluate the effec-tiveness of the cloud system. Some measures are quantitative

while others are only qualitative in nature. Nevertheless, webelieve that the proposed measures as a whole can assure ameaningful analysis for the efficiency and capability of themobile medical service supported by the cloud system.

Evaluation indexes

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

Before the implementation of the cloud system, healthcare workers need write down on paper how many needlesare used and inserted into which acupoints. Therefore, alarge volume of formatted paper is needed for the dailyroutine. It costs the hospital to buy, prepare, and store thepaper. Extra time is hence needed to get things done underthe traditional pen-paper-electronic anamnesis system. Thismeans not only a waste of time and money but also anegative environmental impact. Furthermore, the medicalstaff need take notes on what have been done in theacupuncture treatment. These written notes not only are acommunication means between members of the medicalstaff involved in the treatment but also are what to beadded to the medical records of the patient.

After the implementation of the cloud system, no regularforms need be filled out by hand. All we need to have is atablet computer through which the cloud system can be in-voked. Anything involved in the acupuncture treatment nowcan be handled through the acupuncture record system builtinto the tablet computer.

Confirm modifications

Retrieve histrical records

Input changes in medical records

Make modifications

Start

End

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

Confirm modifications

New regular channel sets

Update acupoint set

Edit acupoint set

Start

End

Enter changes in acupoint

New acupoint set priority

Confirm modifications

Edit acupoint layout

Confirm modifications

Edit regular channel sets

Confirm modifications

Edit acupoint set priority

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

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The time spent in making preparations for an acupuncturetreatment (TPA) and the time spent in keeping a record of theacupuncture treatment (TAR) are two indexes that could beused to evaluate the time efficiency of the cloud systemthrough making a comparison between the amount of labortime for an acupuncture treatment with the cloud system andthat without the system.

2. Punctuality of removing the acupuncture needles (PRA)

The acupuncture needles must stay stuck in the patientsbody for a period of time to complete the treatment. Under theold system, an alarm clock can be used to remind the medicalstaff to remove the needles for a particular patient. This is,however, not able to meet the needs of daily acupunctureservices. At a given point in time, there are often several

patients receiving the acupuncture treatment. Furthermore, fora given patient, not all needles need be removed at the sametime. What makes matters worse is that doctors and nursesusually work on separate occasions. A mechanism to ease theway for communications between medical workers involved inthe acupuncture treatment is strongly needed. It is, however, aserious challenge for the traditional electronic anamnesis sys-tem to integrate relevant information from various sources.Therefore, under the traditional system, it could happen thatthe acupuncture needles are not removed on schedule, causedby negligence due to lack of information integration and poorcommunication between the medical staff.

The cloud system for mobile medical services providesreal-time access to information regarding any acupuncturetreatment in progress. The system develops an alarm deviceto alert the medical staff to remove the acupuncture needles at

Mobile Devices

Calculate Barthel Index

Assist in diagnose/treatment

Synchronize

Historical medical records

Four-Diagnosis

Acupuncture

Add/Update

Add/Update

Notify to Remove Needles

Fig. 6 The structure of themobile system

The Backend System

Western medical Records Review

Patients TCM Records

Four Diagnosis records

Preseciptions

Acupuncture Treatment Results

Assemble Acupuncture Related Data

Acupoints Layouts

Regular Channels

Acupoint Priority

Maintain

Analytical Work

Formulate Helpful Tips

Fig. 7 The structure of theback-end system

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the right time. It will assure the patient a high-quality treat-ment. The punctuality measure under either of the old andnew systems is calculated according to the time lag betweenthe scheduled time to remove the needles and the time whenthe needles are actually removed.

3. Time-saving in data integration after the acupuncturetreatment (TDI)

Under the traditional electronic anamnesis system,health care workers have to key in data of the acupuncturetreatment after the treatment is completed . It takes healthcare workers extra time over the time needed for the treat-ment. The cloud system for mobile medical services, on theother hand, can automatically keep and store medical re-cords when it is invoked, and hence perform the dataintegration function concurrently. These important func-tions allow us to read the historical records as well as thenewly generated records through the system. This automat-ic data storage function of the cloud system represents animprovement in time-efficiency of the acupuncture treat-ment. We accordingly denote the amount of time-saving asTDI.

4. Percentage of un-removed acupuncture needles (RLN)

Leaving acupuncture needles in patients is a significantdereliction of health care workers duty. It may not onlyreduce the effectiveness of the treatment but also threatenthe health and safety of the patients. However, it can still,though only occasionally, happen due to negligence, whichcan be mostly attributable to poor communication betweenhealth care workers, as previously alluded to.

Before the implementation of the cloud system, the acu-puncture needles must be removed based on the records putdown on sheets of paper by health care workers during theearly stages of the treatment. If the records are incorrect and/orif health care workers are not conscientious enough, it canhappen that not all the needles are removed. The cloud system,in contrast, can remind health care workers about what to do ina timely manner. This will surely enhance the quality of themedical service.

5. Accuracy of patient identification (API)

It is well known that correctly confirming a patients iden-tity is the most critical step in not only giving appropriatetreatments to the patient but also ensuring high-quality medicalservices. Hospitals are used to checking patient identificationby identifying at least two of the appropriate identifiers (e.g.,the patients name, and medical record number or personal IDnumber) [12]. In Taiwan, everyone is required to have a healthcare card with her/his name and photo on. However, childrenmay not have a personal photo on their health care cards. Also,it can happen that people do not take their cards with them

when they visit the hospital. In these cases, additional effortsare needed to be made to confirm patients identity.

In addition to the traditional patient identifiers, the cloudsystem adopts photographic techniques to identify patients. Itthus allows us to confirm a patients identity throughmatchingthree patient identifiers: the patients photograph, the patientsname, and the patients medical record number when thepatient checks in at the reception desk of the hospital. Fur-thermore, through the camera on the tablet computer, we canalso take a photograph of the patient right before the acupunc-ture treatment. We can then compare the new picture withthose, if any exist, already stored in the cloud system to makesure that the treatment is given to the right person. This on-sitephotographic confirmation technique enhances the safety ofthe patient receiving the medical service. Photographic iden-tification of patients can assure positive patient identificationand improve patients safety by reducing system errors [13].

6. Human resource management (HRM)

The cloud system for mobile medical services not onlysaves time but also spares health care force. Before the imple-mentation of the cloud system, we need at least 4 man-tasks togive an acupuncture treatment to a given patient. One per-forms the acupuncture, another makes the record, the thirdremoves the needles, and the last keys in the data of theacupuncture treatment to the electronic anamnesis system.

With the cloud system in place, we only need two people toexecute the treatment. One performs the acupuncture andmakes the record in passing, and the other removes the needleswhen the treatment is done. Human resources managementbecomes relatively flexible after the implementation of thecloud system.

7. Impacts of on-site access of medical information (IAI)

The portability of the acupuncture service in fact generatesan edge in providing on-site medical service. With the help ofthe cloud system, the medical staff can access patients med-ical records and provide proper acupuncture treatments for thepatients. This kind of service is in fact invaluable and its valueis sometimes hard to measure.

In summary, it is hard, if not impossible, to have a com-prehensive measure for the effectiveness of the cloud system.We, nevertheless, believe that the evaluation indexes we pro-pose can complementarily illustrate how sound the cloudsystem can be. Furthermore, it is noteworthy that the fact thatquantitative measures can give us the degree of the improve-ment made by the cloud system in more concrete terms thanqualitative measures does not necessarily imply that quantita-tive measure are far more important than qualitative measuresin terms evaluating the effectiveness of the cloud system. Ourultimate goal is to infer from these quantitative and qualitativeindexes the improvement in TCM service quality attributableto the cloud system.

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Result

A field test

To precisely measure the performance of the cloud system, wecarried out a one-month field test prior to the implementationof the cloud TCM service at the Lukang Branch of theChanghua Christian Hospital. Two doctors were assigned toparticipate in the test. In the first half of the test period, theywere required to use the traditional paper-based recordingsystem. Total numbers of patients whose medical records wereprocessed by the two doctors within the first-half-month peri-od were 20 and 22 respectively. The result shows that the twodoctors have similar data-processing skills since they spendcomparable time processing medical data of an individualpatient. During the second half of the test period, the twodoctors were required to process medical data in differentways. One doctor was asked to handle medical data of 12patients using the traditional paper-based recording systemwhile the other doctor handled the same medical data basedon the TCM cloud system. The doctor using the TCM cloudsystem worked more slowly than the other in the beginning,but became much more quickly as time went by. This indi-cates that the cloud system can have a competitive advantagein processing medical data. Finally, the two doctors wereasked to handle an identical set of medical data of 20 patientswith the TCM cloud system. The result shows that the cloudsystem is friendly enough for doctors to become familiar withit after only a short period of time.

Performance of the cloud TCM service

For a month period following the implementation of the cloudsystem, we record details regarding how the cloud systemimpacts on the TCM service. As summarized in Table 2, thecloud system does a better job than the traditional system fromvarious perspectives. Under the traditional electronic anamne-sis system, TPA and TA are about 2 and 3 min per patientrespectively. This, along with the observation that no less than20 patients receive the acupuncture treatment during a typical3-h period, amounts to a saving in working time of more than40 min per 3 h. It means a 7.40 % (i.e. 40/(1803)) gain intime efficiency. Furthermore, under the traditional electronicanamnesis system, TDI is on average 4min per patient while itbecomes about 3 min under the cloud system. Note that underthe traditional system, data entry takes less time since it iseasier to key in data on a PC than on a mobile device. Thisexplains why the saving in TDI time is not that significant.We, nevertheless, believe that the data entry time using a Padwill be inversely proportional to the conversance of users.There will be a big potential for time-saving if proficiencywith the cloud system can improve. The saving in labortime from increased operating efficiency attributable to

the cloud system frees up some human resources for theTCM service.

In addition to the great improvement in operatingefficiency shown by the quantitative measures, the qual-itative measures further indicate the superiority of thecloud system. The cloud system makes it easy to confirmpatients identity through taking a picture of the patientupon receiving any medical treatment. The result alsoshows that the cloud system achieves significant im-provement in the acupuncture treatment. There are nolonger un-removed needles. Furthermore, all the needlesnow can be removed at the time they are expected to beremoved. Furthermore, on-site access of patients medi-cal information provides a means of effective communi-cation between medical workers. These functions allowus to make the most use of the portability feature of theacupuncture treatment. This in fact represents a signifi-cant enhancement in the quality of the TCM service.

Conclusion

One of the most characteristic and attractive features ofacupuncture is that the acupuncture treatment can be givenright at the place where the patient is. Though this on-sitetreatment feature gives acupuncture a tremendous advan-tage over other therapies, it, along with the complicatedprocess of the acupuncture treatment, poses a challenge tomedical workers. The study therefore develops a cloudsystem to make the most use of the on-ste treatment featureof acupuncture.

The proposed cloud system not only offers instant access topatients medical data but also integrates patients new med-ical information from various sources in a timely manner,which helps establish an effective communication system formedical workers involved in a given acupuncture treatment.Our result shows that the cloud system results in a significantsaving in labor time, increasing the flexibility in managinghuman resources of health care. Medical workers now canhave ample time to take care of their patients and to conductextensive medical research. The cloud system hence providesfurther impetus to improve the quality of the TCM service.The effective communication mechanism provided by thecloud system in fact makes other considerable improvementsin the TCM service. It enables doctors to give an on-siteacupuncture treatment to a patient. The system also ensuresthat every acupuncture needle can be removed at the sched-uled time, improving the effectiveness of the acupuncturetreatment.

In sum, this work has illustrated the benefit of providingmobile medical services, supported by automated electronicanamnesis storage and update using Cloud Computing, atLukang Branch of Changhua Christian Hospital in Taiwan.

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The result shows that the contribution made by the cloudsystem to the TCM service is multi-dimensional: cost-effective, environment-protective, performance-enhancingetc. Developing and implementing such a cloud system for

the TCM service in Taiwan symbolizes a pioneering effort.We believe that the work we have done here can serve as astepping-stone toward advancing the TCM service quality inthe future.

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

Medical steps As is To beItems Items

Review a patientsmedical records

Labor (time) cost:1. The patients anamneses must be prepared byHIS in advance. (TPA: 2 min)

2. The doctor reviews the patients medical dataon the computer and writes important information downon paper. (TAR: 3 min per patient to take notes)

Labor (time) cost:1. All data can be freely accessed through Pad. The doctorcan retrieve the patients anamneses from Pad on site.There is no need to make hand-written notes on paper.(TPA & TAR: 10 s per patient)

Risk: Confidential data may be disclosed, which, however,can be overcome by adopting an encryption mechanism.

Record diagnosisand acupunctureresults

Labor (time) cost:The doctor writes down diagnosis results on paper.Furthermore, the doctor must record the acupuncturetreatment results manually within her/his memory.After the treatment is completed, medical workersmust key in the medical data. (TDI: 1 min +1 minand 10 s per patient+2 min)

The doctor hands over the patients medical recordsand memos to another doctor. However, data maybe lost in the process.

Overhead cost:Numerous sheets of paper are used to recorddetails of the acupuncture treatment in a typicalday. (100 pieces of paper per day)

Risk: Diagnosis and acupuncture results may notbe completely written down when the doctorsmemory does not serve him correctly. Besides,papers of the medical records tend to get lost.

Labor (time) cost:The doctor need not write down the diagnosis andacupuncture treatment results. Instead, she/he canupdate the patients medical data through on-sitemobile devices. Data synchronization between the padand the server is executed automatically. (TDI: 3 min)

Any doctor with an assess code can view the patientmedical records and memos made in the passing oftime. Data are kept in pads seamlessly and safely.

Overhead cost:No paper is needed for manually recording detailsof the acupuncture treatment.

There will be no loss of data. All the data are nowsynchronously stored in the server through Pad.

Improve theacupuncture service

Lack of information integration and poorcommunication between medical workers involvedin the acupuncture treatment make it hard to haveall the needles removed as scheduled. Furthermore,it could, though very occasionally, happen that someneedles are left behind and they are removed onlywhen they are found. (Punctuality: not good enough)(Un-removed needles: possible)

The cloud system can remind medical workers toremove the needles when the treatment is done.It will also make sure that all the needles are removed.(Punctuality: perfect) (Un-removed needles: none)

Confirm patientsidentity

The patients health care card is used to verify her/hisidentity. However, children may not have a personalphoto on their health care cards. Also, it can happenthat people do not take their cards with them whenthey visit the hospital. These cases call for additionalefforts to confirm patients identity and mistakes maystill, though very occasionally, happen. (API: not perfect)

The cloud system allows us to take an on-sitepicture of the patient upon receiving any medicaltreatment, through which the patients identitycan be easily confirmed with no error. (API: perfect)

Improve humanresourcemanagement

Four man-tasks are needed to perform the acupuncture,to write down the records, to remove the needles, andto key in the medical data. (HRM: 4 man-tasks)

Only two man-tasks are needed. One perform the acupuncturetreatment and make the records in passing. The other isresponsible for removing the needles. (HRM: 2 man-tasks)

Enhance on-sitemedical services

Many extra efforts must be made for giving theacupuncture treatment to patients outside theoutpatient clinic room. Medical informationof the patient cannot be easily exchangedbetween medical workers.

With the cloud system, the medical staff can accesspatients medical records and proper in-time andproper acupuncture treatments for the patients. (IAI: great)

Analyze historicalmedical records

Labor cost:Patients data must be retrieved from HIS andcopied to destinations for further processing. (1 min)

Computer time cost:Much time is required to transfer data betweenheterogeneous systems. (very time-consuming)

Labor cost:Patients medical records can be directly transmitted from theTCM cloud database to designated destinations. (

Discussion

There are several issues needed to be addressed for wideapplication of the TCM cloud system. First, the Wi-Fi pene-tration rate needs to be raised in the hospitals for which thecloud system will be established. Although 3G-carried mobiledevices can operate without Wi-Fi, the transferring speed andthe fair cost tend to balance out the great merit. On the otherhand, the cloud system for mobile medical services must workwithin a Wi-Fi environment. This in fact has posed a bigproblem for many hospitals in Taiwan, and this also has beenthe case for many hospitals in regions such as Europe, Asia,and even North America.

However, with the rapid development of information tech-nology, the Wi-Fi service penetration has been increasing inrecent years. According to a prediction made by a globaltelecommunications equipment company, the number of pub-lic Wi-Fi Hotspots is set to proliferate, growing from 0.8million at the end of 2010 to 5.8 million by the end of 2015[14]. Furthermore, the continued expansion of broadbandservices provides a solid foundation for further growth inWi-Fi adoption. Thus the problem of low Wi-Fi penetrationrate will be solved very soon.

Second, the medical cloud system we propose is builtunder the Android operating system (OS). Therefore, themobile device is limited to those compatible with theAndroid OS. Although Android is by far the most popularsmart phone OS, iOS also plays an important role in thetablet and smart phone markets. A key factor in popularizingthe medical cloud system is to make it compatible withvarious operating systems, a goal we will pursue in the nextstage.

Consequently, we chose 7-in. tablets as the mobile device.The most important advantage of a 7-in. tablet is its suitablesize for mobile medical services. Compared with 10-in. tabletslike the iPad, 7-in. tablets are characterized by small butconvenient size. Furthermore, a 7-in. tablet can fit neatly intothe pockets of the white garb, making it easy for medicalworkers to bring the tablet with them. Also, the medical staffnow can easily take notes on the wrist. Another importantadvantage of the 7-in. tablet is its affordable price. Prices of7-in. tablets are usually lower than those of 10-in. tablets.From the perspective of cost-effectiveness, 7-in. tablets arehence more competitive than 10-in. tablets.

The last concern is the choice of a reliable server. The cloudsystem for mobile medical services requires a large amount ofdata storage and transformation. The amount of data is con-tinuously increasing. Furthermore, the server of the cloudsystem must be able to allow multiple users to access datafiles simultaneously. The information system for the medicalservice is much complex than that those for other industries. Aserver with trustworthy performance and great stability isnecessary to assure a dependable cloud system.

When the cloud system is applied tomobile medical services,data privacy and security become extremely important. Thecloud system must be able to guarantee the confidentiality andintegrity of medical data. Many proposals that are presented touse cloud computing for mobile medical services also addresssecurity concerns in mobile cloud computing [10]. Reinforcinginformation security and defending the system from unwantedintrusions become the essential issues [10]. With the progress ofthe cloud system for mobile medical services, innovations inmanaging data privacy and security will also be re-quired to complement the demand. The discussion indi-cates that security updates to protect existing infrastruc-ture are a continuous necessity [15]. Therefore, if wewant the cloud system to have good performance, a procedureto make sure of security must be built in inside the infrastruc-ture so as to protect data from flowing out [15].

Although mobile devices have limited computational ca-pacity to run secure multimedia signal processing algorithmsin mobile applications [15], it has become an imperative forthe cloud system for mobile medical service. For example,HTTP basic access authentication, a basic method for au-thentication, asks users to provide a user name and a passwordupon making a request. Besides, the Radio frequency identi-fication (RFID) is often used to identify assets and people inhospitals [16], and it can be used to check the identification ofpatients and medical workers [17]. Although the RFID ap-proach still has some security concerns that are needed toimprove [16], it should be considered in the future versionof the cloud system. An isolation mechanism should beestablished to make sure that electronic anamnesis is notcommingled with other cloud databases, thus ensuring datasecurity, data integrity, and data encryption [15].

At the current stage, the security of our system is not strongenough to keep the system from being infiltrated. For theforeseeable future, we will continue to develop several infra-structure devices, including confidentiality of data transfer,authentication, and authorization [18], to enhance security .

The application of mobile devices to pervasive healthcareinformation management has already been acknowledged andwell established [19]. However, mobile devices have not beenintroduced for TCM medical services. The study initiates acloud system that is particularly suited for mobile TCMmedicalservices. Although there is still room for improvement on theproposed cloud system, it in fact lays the groundwork for furtherdevelopment of a sound cloud system for mobile TCM services.

Acknowledgments This study was supported by a grant fromChanghua Christian Hospital, Changhua, Taiwan (No.:101-CCH-IRP-75). The authors would like to express their sincere appreciation to Mr.Bo Shang Chao and his staff at Department of Information Management,National Formosa University, for helping fix program codes, and to Dr.Shu-ching Lee and Dr. Zong-syun Jiang from Department of ChineseMedicine at Changhua Christian Hospital in Taiwan for assisting withdata collection.

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

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

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J Med Syst (2013) 37:9978 Page 13 of 13, 9978

A Cloud System for Mobile Medical Services of Traditional Chinese MedicineAbstractBackgroundMaterials and methodsSettingThe cloud system for mobile TCM serviceSystem design and deploymentThe system flowSystem structure

An application of cloud computing to the TCM anamnesis systemThe application of cloud computingEvaluation indexes

ResultA field testPerformance of the cloud TCM service

ConclusionDiscussionReferences