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journal homepage: www.intl.elsevierhealth.com/journals/ijmi

Ubiquitous healthcare service using Zigbee and mobile

phone for elderly patients
Hak Jong Lee a , Sun Hee Lee b , Kyoo-Seob Ha c , Hak Chul Jang d, , Woo-Young Chung d ,
Ju Young Kim e , Yoon-Seok Chang d , Dong Hyun Yoo b
a

Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital,
Institute of Radiation Medicine, Seoul National University Medical Research Center, Clinical Research Institute,
Seoul National University Hospital, Seoul, Republic of Korea
b Department of Medical informatics, Seoul National University Bundang Hospital, Seoul, Republic of Korea
c Department of Psychiatry, Seoul National University College of Medicine,
Seoul National University Bundang Hospital, Seoul, Republic of Korea
d Department of Internal Medicine, Seoul National University College of Medicine,
Seoul National University Bundang Hospital, Seoul, Republic of Korea
e Department of Health Promotion Center, Seoul National University College of Medicine,
Seoul National University Bundang Hospital, Seoul, Republic of Korea

a r t i c l e

i n f o

a b s t r a c t

Article history:

Objective: To investigate the efcacy of a u-healthcare service using Zigbee and mobile phone

Received 21 June 2006

for elderly patients with diabetes mellitus or heart diseases.

Received in revised form 7 July 2008

Materials and methods: From July to October, 2005, 29 patients were enrolled in our study. Two

Accepted 7 July 2008

selected u-healthcare items, ECG and blood glucose measurement, were monitored.
Twenty patients were provided with ZigBee built-in blood glucometer and mobile phones,
and were instructed on using a web service where the measured blood glucose could be

Keywords:

transmitted directly to the web and be administrated. Nine patients participated in ECG

Ubiquitous healthcare

monitoring, by using a wireless, transmittable ECG recording instrument equipped with

Mobile phone

ZigBee protocol attached to their chest.

Elderly patient

Daily average transmission frequency, rate of transmission loss, and error reasons were

Self monitoring blood glucose

analyzed. In addition, the patients were asked to score their degree of satisfaction about the

(SMBG)

sensors and u-healthcare services.

Electrocardiography (ECG)

Results: The mean transmission frequencies were 2.1 times/day in blood glucose monitoring
and 6.1 times/day in ECG. The patients satisfaction scores of the blood glucometer and service used in this research were 8.59 and 9.01 of 10 points, respectively. The mean satisfaction
scores about ECG sensor and ECG monitoring services were 5.79 and 7.29, respectively.
Discussion: Despite the many problems still encountered such as technological problems
related to sensors and some problems like battery replacement, we could transfer the data
of glucometer and ECG sensors to web-server via ZigBee protocol. Authors think the ZigBee could be one of components of wireless u-healthcare systems in the future due to its
advantages of lower power consumption.
2008 Elsevier Ireland Ltd. All rights reserved.

Corresponding author at: Department of Internal Medicine, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu,
Seongnam-si, Gyeonggi-do, 463-707, Republic of Korea. Tel.: +82 31 787 7005; fax: +82 31 787 4052.
E-mail address: janghak@snubh.org (H.C. Jang).
1386-5056/$ see front matter 2008 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijmedinf.2008.07.005

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1.

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Introduction

The interest in ubiquitous healthcare (u-healthcare) is

increasing with the spread of ubiquitous information technology (IT). In addition, the need for a new healthcare system
that is usable anytime and anyplace is growing due to the
paradigm shift from health supervision to health preservation, the increasing number of the elderly, the development of
ubiquitous technology, and the cutting-edge IT infrastructure
available in new cities and apartment complexes.
With the advent of the internet and wireless technology,
a world wide communication system is available enabling
people to communicate at any time and anywhere and to
exchange information online. Telemedicine systems have
been proposed for nearly two decades as a means of supporting patients with chronic medical diseases [1].
In general, u-healthcare can be divided into three sections
depending on the transfer range of the patients information:
u-healthcare within medial institutions, between individuals
and medical institutions, and among different medical institutions. Currently, newly-built and large hospitals are trying
to operate these hospital information systems by focusing on
hospital information systems such as order communication
systems (OCS), picture archiving and communication system
(PACS), electronic medical record (EMR), visual information
system, and groupware. However, u-healthcare between individuals and medical institutions has only been undertaken
experimentally using mobile phones and sensors and only in
some organizations. In addition, there have been few cases
where the problems of u-healthcare service were analyzed by
running a test service to real patients in medical institutions.
The elderly population of over 65-year-olds in South Korea
is rapidly rising from 7.2% of the total population in 2000 to a
projected 14% in 2019 and 20% in 2026. Therefore, the necessity

of u-healthcare is expected to increase with this development

of the aging society.
ZigBee is a new, wireless standard protocol. The features of
ZigBee include very low-cost, very low power consumption,
two-way and wireless communications standard. Solutions
adopting the ZigBee standard are increasing and it is being
embedded in consumer electronics, home and building
automation, industrial controls, toys, games, and medical
sensor applications. To our knowledge, there have been no
previous reports of the use of ZigBee wireless protocol in
healthcare services.
Therefore, in this research, the purpose of this study is
to investigate the efcacy of u-healthcare experiment service
using ZigBee wireless protocol in monitoring the blood glucose
level and electrocardiography (ECG) results.

2.

Materials and methods

This prospective study was performed with the approval of

our institutional review board and the informed consent of all
patients.
In order to execute the u-healthcare service for homenetwork, we selected 29 patients who visited Seoul National
University Bundang Hospital (SNUBH) in the outpatient
department routinely and who also reside in a nearby apartment complex. Two selected u-healthcare items, ECG and
blood glucose monitoring, were monitored from July to
October, 2005.
Among the 29 patients, 20 participated in blood glucose monitoring. In order to measure the blood glucose, the
patients were provided with ZigBee built-in blood glucometer
and mobile phones, and were instructed on using a web service where the measured blood glucose could be transmitted
directly to the web and be administrated.

Fig. 1 A schematic drawing of ubiquitous healthcare services using ZigBee module. The data measured were transferred to
web-server via ZigBee protocol. The clinicians can assess their patients by logging on the server.

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70.1

Nine patients participated in ECG monitoring, by using a

wireless, transmittable ECG measuring instrument equipped
with ZigBee protocol attached to their chest. The ECG
was measured every 1 h and automatically analyzed in the
recorder. If patients experienced symptoms of palpitations or
chest pain, they were asked to push a button on the top of the
sensor. Whenever the patients pushed the button, the ECG
was measured and sent to the web-server immediately. The
data sent to the web-server were interpreted by experienced
cardiologist (W.Y.C.).
Fig. 1 presents a diagram of the u-healthcare services. The
data obtained from the glucometer and ECG sensor were transmitted to the web-server via mobile phones or IP transmitter
using ZigBee protocol. Later, when the patients visited the outpatient clinic, the doctors assessed the data provided by the
u-healthcare services. In addition, the patients were provided
with personal education on the use of the glucometer and ECG
sensors. Once a week, a nurse in charge conducted a telephone
survey with the patients by using a questionnaire investigating convenience and satisfaction. Daily average transmission
frequency, rate of transmission loss, and error reasons were
analyzed. In addition, the patients were asked to score their
degree of satisfaction about the sensors and u-healthcare services.

Fig. 2 This gure shows the levels of blood glucose

expressed as graph. Note that the horizontal lines
representing the upper and lower normal range.

89.33 (520/577)
19.86 (520/2618)

Mean ages

1.91 (11/577)
0.42 (11/2618)

5.9
35.3
41.2
17.6

2.61 (15/577)
0.57 (15/2618)

1
6
7
3

5.04 (29/577)
1.11 (29/2618)

<60
6069
7079
80<

1.04 (6/577)
0.23 (6/2618)

Ages

Percentage of problematic data (%)

Percentage of total data (%)

52.9
47.1

Glucometer problems

9
8

Battery problems

Male
Female

Mobile phone problems

Sex

Unknown reason

Percentages (%)

Electric discharge

Number

Table 2 Reasons of problems in blood glucose data transmission

Characteristics

Total

Table 1 General characteristics of patients participated

in blood glucose monitoring services

22.03 (577/2618)

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Table 3 General characteristics of patients participated

in ECG monitoring services

3.

Results

3.1.

Results of blood glucose monitoring service

Characteristics

Seventeen patients used the blood glucose measurement service, nine male and eight female, after three dropped out
due to a large difference in data between the existing blood
glucometer and the one provided during the service, troublesome defects with the mobile phones, and individual reasons
(Table 1). The average age was 70.1 years old.
The suggested frequency of blood glucose measurement
was four times a day: before breakfast meal, 2 h after meal,
before sleep, and in the event of any other symptoms of
hypoglycemia (Fig. 2). However, the daily average frequency of
transmission was only 2.13 times. We conrmed by telephone
interviews when the information measured by the patients
was not saved in the web-server. The rate of transmission loss
of blood glucose data was 22.03% and the reasons included
unknown, 89.39%, defect of mobile phones, 5.04%, defect
of batteries, 2.61%, defect of blood glucometer, 1.91%, and
electric discharge of mobile phones, 1.04%. We considered
that the most likely causes of the unknown reasons were
problems related to communication between the sensors and
mobile phones and those of mobile phones and web-server
(Table 2).
The patients satisfaction scores of the blood glucometer
and service used in this research were 8.59 and 9.01 of 10
points, respectively.
In addition, we investigated opinions about the glucose
monitoring services. The most serious dissatisfaction was
about the glucometer and mobile phones. Many patients
complained of short battery life since the battery consumption period of the ZigBee built-in glucometer was only 4
weeks. Besides, many also added that there were difculties
in operating mobile phones and discomfort from checking
repeatedly due to various errors. In addition, there were incidents where a gap of over 20 mg/dl appeared between readings
from the existing glucometer and the new, ZigBee built-in
one. The second most common complaint was about the
method of blood glucose measurement because it was somewhat invasive, although this problem is not restricted to this
research.

3.2.

Results of ECG monitoring service

Six patients, three male and three female, completed the ECG
test service after three dropped out due to fear of electromagnetic waves, skin eruption at the place where the ECG line and
electrode were attached to the body, and troublesome problems of attaching ECG (Table 3). The average age of the subjects
was 70.3 years old.

Number

Percentages (%)

Sex

Male
Female

3
3

50
50

Ages

<60
6069
7079
80<

1
2
2
1

16.7
33.3
33.3
16.7

Mean ages

70.3

Fig. 3 The graph shows the baseline trembling of ECG. It

is one example of unreliable data which cannot be
interpreted.

We recommended that the patients measured ECG once

per hour and also added the measurement by pressing
the event record button whenever they felt palpitations or
chest discomfort. Daily average transmission number was
6.1 times. Among the transmitted data, 42.1% was unreliable and only 57.9% of the actually transmitted data was
useful. The reasons for the abnormal data were tremble of
base line in 48.7%, error in automatic interpretation (e.g.
heart rate is zero in case of abnormal ECG data, or normal
ECG even though the ECG is unable to be interpretable.) in
26.9%, and zero heart rate transmitted for unknown reasons
in 24.4% (Fig. 3, Table 4).
In case of ECG, we could not verify accurately the time at
which the patients attached the ECG electrodes, so we were
unable to conrm the transmission omission rate. We estimated that the omission rate was high when we realized from
the patients telephone interviews that there were many incidents when patients were measuring ECG but the data were

Table 4 Reasons of problems in ECG data transmission

Percentage of problematic data (%)

Percentage of total data (%)

Tremble of baseline

Interpretation error

Heart rate zero of

unknown reason

48.7 (342/702)
20.5 (342/1668)

26.9 (189/702)
11.3 (189/1668)

24.4 (171/702)
10.3 (171/1668)

Total

42.08 (702/1668)

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Table 5 Comparison of data expected and transported

Glucometer
Data number expected
Data transported via Zigbee
Mean transport number per person (Standard deviation)

5712 (4/day/person)
2168 (38%)
2.13 (0.49)

not transmitted (Table 4). The mean satisfaction scores about

ECG sensor and ECG monitoring services were 5.79 and 7.29,
respectively.
The most common discomfort with the ECG monitoring
service was about the ECG sensor and mobile phones. Specic
opinions included discomfort of changing batteries due to the
limited battery life of only one day and problems with skin irritation while attaching the ECG instrument. In addition, many
mentioned that the measurement was troublesome since the
operation method of the ECG sensor was complicated to the
patients and that discomforts were suffered in daily life due
to the 24 h attachment of the ECG electrode and lines. Moreover, there were battery problems of the mobile phones due to
frequent data transmission.
The cardiologist who interpreted the ECG results rst
mentioned that the automatically transmitted data and transmitted data due to patients unusual event need to be
distinguishable to improve the evaluation quality. He also
mentioned that at least three channels are required for the
analysis of ECG shapes and that the base line lter should be
able to be applied.

4.

Discussion

Several studies about telemedicine in caring for chronic diseases such as diabetes mellitus were reported. A recently
published randomized trial of intensive insulin therapy versus usual care among young patients with type 1 diabetes
documented greater improvement in HbA1c from intensive treatment (including intensive face-to-face advice and
support) in the subgroup of patients least competent in
self-management [2]. In other reports, pro-active call center
treatment support (PACCTS) achieved an average reduction of
0.49% HbA1c in patients who were moderately or poorly controlled at baseline [3]. According to reports of Yoon et al., the
educational intervention using the Internet and a short messaging service (SMS) by cellular phone rapidly improved and
stably maintained the glycemic control of the patients with

ECG
12096 (24/day/person)
1668 (13.8%)
6.06 (2.32)

type 2 diabetes mellitus [4]. Whereas, in other reports, Farmer

et al. reported that despite good evidence for their acceptability to patients, there was no overall evidence of improvement
in glucose control [1,5].
Despite the absence of consistent data, the American Diabetes Association recommends self-monitoring blood glucose
(SMBG) for all insulin-treated patients with diabetes. According to Murata et al. intensied blood glucose monitoring
resulted in signicant and sustained reductions in HbA1c in
stable, insulin-treated subjects [6].
In the ECG analysis, there are many reports about the clinical usefulness of telecardiology [710]. In a study comprising a
systemic review of the literature on telecardiology assessment
from 1992 to 2003, studies of home care applications in cardiology, particularly management of congestive heart failure, were
of the highest quality, giving a high degree of condence in
their ndings. Magrabi et al. suggested a web-based approach
for electrocardiogram monitoring in the home [11]. However,
studies of telecardiology about pediatric or non-emergency
cases showed poor quality [12].
Even though more studies are needed to conrm the clinical evidence that telemedicine is helpful in caring for the
patients of chronic medical disease, telemedicine and telecaring certainly have a role to play in monitoring the status of the
patients (Table 5).
We used the ZigBee protocol as a wireless communication
method between sensors and mobile phones or IP receiver.
Among the several available wireless protocols, the most outstanding features of ZigBee include its extremely low power
consumption of about 50 mW, which is very low compared
with that of local area network (LAN) (1 W) or Ultra Wideband
(UWB) (200 mW).
Table 6 reveals comparison of ZigBee technology to other
technologies used for similar purposes. Due to its lower power
and cost, ZigBee promises to become widely used in the elds
of industry, home-network, and healthcare.
Even though there were several inconveniences in using
the sensors, some of these are not restricted to the uhealthcare service and are also present in the standard

Table 6 Comparison of Zigbee technology with other technologies

Market name
Standard
Application focus
System resources
Battery (days)
Bandwidth (KB/s)
Transmission range (m)
Success metrices

ZigBee

Bluetooth

NFC

802.15.4
Monitoring and control
432KB
1001000
20250
1100
Reliability, power, cost

802.15.1
Cable replacement
Over 250KB
17
720
110
Cost, convenience

13.56 MHz
Barcode replacement

<1
0.1
Cost, convenience

RFID
433900 MHz
Multi-barcode replacement

<1
05
Cost, convenience

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Summary points
What was already known before our study
The need for a new healthcare system that is usable
anytime and anyplace is growing.
Studies about telemedicine in caring for chronic disease such as diabetes mellitus were reported.
Even though more studies are needed to conrm
the clinical evidence that telemedicine is helpful in
caring for the patients of chronic medical disease,
telemedicine and telecaring certainly have a role to
play in monitoring the status of the patients.
What did our study add to our body of knowledge
This is the rst study to transfer the data of glucometer
and ECG sensors to web-server via ZigBee protocol.
The ZigBee could be one of components of wireless
u-healthcare systems in the future.

measuring procedures. Furthermore, the satisfaction of the

patients about u-healthcare services was relatively high and
they expected the services to nd wide application.
Internet-based, disease management systems for chronic
disease are becoming popular universally. Numerous online
education, exercise, and nutrition programs are used by
diabetic patients and their families. In our results, the service
satisfaction levels were high.
However, this study had a few limitations. First, it was
mainly focused on the technical success rate rather than the
clinical importance. To prove the clinical usefulness of uhealthcare in dealing with blood glucose level and ECG, further
studies focused on clinical impact are needed. Second, the
patient sample was small and a much greater number of participating patients need to be included in the future study for
detailed effectiveness evaluation. Third, the participants were
interviewed on a weekly basis, and it may induce a bias in the
assessment. And, the satisfaction scores were so subjective
depending on individual.
Despite the many problems still encountered such as technological problems related to sensors and some problems like
battery replacement, we could transfer the data of glucometer
and ECG sensors to web-server via ZigBee protocol. Authors
think the ZigBee could be one of components of wireless uhealthcare systems in the future due to its advantages of lower
power consumption.

Acknowledgements
Contribution: S.H.L., K.S.H., W.Y.C., J.Y.K., Y.S.C., and D.H.Y. performed the data collection and substantive data analysis. H.J.L.
and H.C.J. contributed to the study design, data analysis, drafting, review of manuscript and nal approval of the version to
be submitted.

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