Mediterranean Journal of Pacing and Electrophysiology

A ZigBee-based ECG transmission for a low cost solution in home care services delivery

F. Vergari, V. Auteri, C. Corsi, C. Lamberti

Dipartimento di Elettronica, Informatica e Sistemistica (DEIS)

ALMA MATER STUDIORUM, Universita’ di Bologna
Viale Risorgimento, 2. 40136 BOLOGNA

Introduction
Telemedicine can make available the benefits of new technologies, especially information and
communications, in providing medical care. In particular it can promote international collaboration,
facilitate integration of eHealth in health systems, support interregional initiatives among groups of
countries that speak a common language, and document the best practices and report on them.
Home care provided in the patient's home is one of the main field in which telemedicine can effectively
change the way of providing health care. The availability of portable and communicant devices, services
and systems, is very useful for health purposes for filing, exchange and treatment of medical data, if
regulated by specific administrative, legal and ethical rules. It allows fast out-of-hospital assistance and
integrated services to elderly, sick, disabled, lonely citizens and support to the families.
Italian experience in telemedicine is very limited and primarily regards tele-consultation in radiology and
home care in selected patient populations. Only few application fields are spread all around the country,
such as 118, CUP and networks for organ transplantation. In 2006, Italian population counted 59 million
of people of which 14.1% between 0 and 14 years and 19.9% over 65 years. 35% of senior citizens lived
alone. In addition, in this environment, the citizen/patient's needs are changing since they want to be
more responsible of their own health care, acting as consumers, and they require painless and non-
invasive methods of diagnostic and treatments. In the face of these changes, home care services could
represent an efficient answer to these needs.
Heart disease is the main cause of early disability and premature death in western countries and its
incidence increases with age. Most of the cardiac deaths occur outside of the hospital and new
strategies are needed to reduce the time before treatment and to detect as early as possible the onset
of cardiac events. The ECG is the only useful diagnostic tool that is immediately available to assess the
probability of cardiac events. Therefore many studies have been focused in the design of a highly
intelligent, extremely friendly and easy to use, personal portable device for the early detection and
interpretation of ECG and the transmission of alarms to the relevant healthcare providers.
OLDES (Older People’s e-services at home) is an EU co-funded project under the IST Programme that
offers new technological solutions to improve the quality of life of older people, through the
development of a very low cost and easy to use entertainment and health care platform, designed to
ease the life of the elderly in their homes. The project aims: to improve the quality of life and health
conditions of the senior citizens (fragile/alone, or affected by pathologies); to keep them at their home
for longer, contributing in keeping them active; to guarantee a correct use of the social and health
services limiting the welfare costs. From a technological point of view, a new communication system
(based on a technological/computer sciences networks and on the local social resources), involving the
social sanitary services and the local social resources, has been proposed. The system monitors and
collects updated biological data, integrating in a single board a device for signal acquisition, processing
and wireless communication (“motes”) in order to create a “Body Area Networks”: a varying number of
motes can acquire biological signals and complementary ones, transmit them to a remote “base station”
for the processing. The medical devices installed at the patient's home include a sphygmomanometer, a
digital scale, a coagulometer, a glucosimeter, a digital thermometer, a 1-lead ECG, a saturimeter and a
spirometer. These devices are connected to a “house concentrator”, a low cost pc, responsible for
acquisition, storage and transmission of sensors data to a central server (Figure 1). In case of alarm,
data are automatically transmitted from the server to healthcare providers or healthcare providers and
physicians, anytime, can connect to the server to check the patient’s status.

Figure 1. Medical devices selected for the OLDES project accomplishment

The most important feature of these devices is represented by the mean of interaction between the
patient and the whole system. Since the main users are elderly patients, it is necessary to simplify the
use of the computer and of the system itself. Mouse and keyboard have been replaced by a remote
control which is the only mean of interaction between the patient and the system: pressing conveniently
the buttons, the user controls all the system’s functionalities.

Materials and Methods

In this project, we realized a portable, wireless ZigBee based ECG monitoring device prototype. The
device is able to acquire, sample and transmit over the air a single lead ECG signal to a remote base
station (e.g. PC, laptop) in real time.
Considering the peculiar features of telemedicine, that is the absence of direct contact between the
patient and the physician and wireless connectivity, is fundamental for the development of efficient
remote monitoring systems in order to provide continuous, real-time and accurate information about
health conditions of the patient.
The availability of new low power, highly flexible wireless protocols paved the way for many innovative
applications in telemedicine, along with a series of new challenges and difficult design decisions.
For the choice of a reliable, robust and flexible transmission wireless protocol, some aspects must be
considered: battery life of remote nodes, data loss over the air, device pairing, limited range, ease of
network creation and maintenance, data relay over different nodes, multiple data incoming on the base
station at the same time. ZigBee is one of the most prominent wireless protocols that offers an efficient
relay protocol, good transmission range, flexible network structure (allowing various network
topologies) with emphasis on power consumption efficiency, supporting several “low power”
transmission modes which allow for higher autonomy and battery life. In Table 1, ZigBee protocol
features are compared with other transmission protocols. Using real time ECG waveform data is a good
“stress test” for this transmission protocol.
 Table 1. Wireless protocol features

In Figure 2 the architecture of the ECG monitoring device prototype is shown.

Figure 2. Single lead ECG monitoring system architecture

The ECG signal is acquired through a single lead, amplified and filtered by an analog circuit and then
sampled by a low power microcontroller (TI MSP430F149) mounted on a Multi-Sensor-Board (developed
by Ducati Sistemi) that includes accelerometer, compass and GPS. Therefore data is transmitted over
the air using a ZigBee module (Telegesis ETRX1).
The system in its current version supports only a point to point network connection and the developed
MSP430 firmware allows the acquisition of either the ECG signal or data from the sensor array but not
all of them at the same time.
The base station is composed of a Telegesis ZigBee module connected to the PC through a UART to USB
transceiver form FTDI; the end terminal can be any computer equipped with a USB port and running an
operative system for which is compatible USB to UART FTDI driver. On the base station an application
reads the data stream from USB port applies some filtering and visualizes the real time ECG track on the
screen.
The data processing flow chain can be represented as shown in Figure 3.
 Figure 3. Data processing flow chain

The analog circuit is kept very simple trying to minimize board space. The signal, acquired by a couple of
electrodes, is preconditioned trough capacitive coupling for blocking unwanted DC components and a
high frequency low pass passive filter in order to avoid the RF interference. The signal is then amplified
trough a low-power high CMRR instrumentation amplifier (AD623); after this, it is filtered with an active
low-pass filter at 17 Hz (that warrants a very clean signal, good enough for monitoring purposes) and
amplified in order to span the full range of the A/D converter. The global gain of the circuit is 750
allowing an input range of ± 2 mV (Figure 4).

Figure 4. Schematic description of the analog circuit

Following the analog circuit, the signal is sampled by the ADC of the MSP430F149 with a sampling
frequency of 500 Hz and a resolution of 12 bit. Double buffering is used to prevent data loss during
transmission; when a buffer is full, the bytes transmission starts and the sampling buffer is switched.
The microcontroller sends the samples trough an UART port to the ZigBee module that takes care of
sending data to the receiver (the “coordinator” in ZigBee terms). The ZigBee module also supports a
deep sleep mode in which power consumption is measured as low as a 2.3 mW ; therefore the relation
between the sampling rate, the buffer size and baud rate is very relevant in order to reduce as much as
possible the power consumption.
The coordinator receives the data sent by the ECG Monitor and processes them trough a custom built
.NET C# application that performs real-time visualization, QRS detection and computation of HRV
parameters. To perform the QRS detection, a modified Pan and Tompkins algorithm is used; first, the
signal is filtered by a pass-band filter; then, following a differentiation step, the absolute value is taken
and a running average is performed on the resulting signal. At this point, a dynamic threshold is
computed, considering half of the difference between the maximum and minimum of the signal in a
moving window lasting three seconds. The local maximum is finally identified on the original signal.
Once the RR time series has been acquired is then possible to display HR and HRV information (Figure 5).

Figure 5. A: ECG signal pre- (up) and post-processing (bottom); B: Final ECG signal and HR display; C: HRV
frequency analysis (left) and intervals histogram (middle), together with the HRV time domain measurements
(right)
Discussion and Conclusion
The aim of our project was to realize a wireless ECG monitoring device prototype, able to acquire,
sample and transmit a single lead ECG signal using a ZigBee protocol for its low-power functionalities.
In this system since power consumption is very influenced by the ETRX1 (75% of the total), there is a
wide gap between the system functioning with the radio module in transmission mode and in deep
sleep. The attempting to realize an optimized storing/transmission cycle in order to reduce the
consumption of power keeping Telegesis module in sleep mode as long as possible failed since, if too
many bytes are sent to the radio module too quickly, the module is not able to send all of them,
resulting in a data loss at the receiver end. Therefore, it was not possible to realize an optimized
store/sleep-store/send cycle as we intended to. To override this limitation some possible solutions are
available in order to reduce the amount of bytes to send to the transmission buffer: data compression
or motes local processing. A proprietary firmware for the ZigBee stack on the ETRX1 module is also an
alternative solution.
The test regarding module signal coverage was performed using two indicators of signal strength that
we can read by commands implemented in the firmware of Telegesis module: the Link Quality Indicator
(LQI) and the Received Signal Strength Indication (RSSI). We used the RSSI as the preferred indicator and
the results of our test are shown in Figure 6. As we expected, the RSSI is much stronger outdoor while
indoor the signal strength falls quickly; however the coverage is good enough to cover two or three
rooms depending on the walls thickness and the relative position of transmitter and receiver as shown.

Figure 6. Received Signal Strength Indicator (RSSI) test results, indoor (left) and outdoor (right)
Regarding ZigBee protocol, the flexibility and robustness of the network protocol should be investigated.
ZigBee strength lies in its ability to support a wide variety of network topologies: for continuous
monitoring (at home or hospital) the range and signal strength provided by a point-to-point connection
would not be adequate to provide full coverage of the environment; a network with a “sink” (the base
station), the sensor, and a number of “router” nodes would be an ideal set-up that should be tested.
Finally, the integration of information collected from various sensors on the Multi Sensor Board should
be investigated since it could provide additional information regarding the status of the patient, for
example the data from the accelerometer, together with the ECG signal, could allow the monitoring of
the subject’s activity.
In this study we proposed a solution based on an intelligent wireless personal ECG monitor that has
professional recording and processing capabilities on the house concentrator; it is concretely cost saving
and no specific infrastructure is required; healthcare providers are involved only if necessary and
communications are based on standard external tools. The proposed solution is included in a complete
project, that represents a real example of how healthcare could become personalized, wearable,
ubiquitous moving from “how to treat patients” to “how to keep people healthy and prevent illness”,
supporting healthy lifestyle, increasing emphasis on prevention instead of treatment, transferring the
secondary care to primary care (like in Scandinavian countries) and providing the basis for early
discharge, cheaper recovery and rehabilitation in home situation, improving access to service supplying
support at any time and place.

References
www.oldes.eu
www.istat.it
Telegesis, ETRX1-ETRX2 AT Commands Manual http://www.telegesis.com/pdf/Zigbee/TG-ETRX-
R211-Commands.pdf
Heart Rate Variability. Standards of measurements, physiological interpretation, and clinical use:
Task force of the European Society of Cardiology, and the North American Society of Pacing and
Electrophysiology, Circulation. 1996;93:1043–1065.
J. Pan and W. J. Tompkins, A real-time QRS detection algorithm. IEEE Trans. Biomed. Eng., BME-
32 (3):230-236, 1985.
K. Srinivasan and P. Levis. Rssi is under appreciated. In Third Workshop on Embedded
Networked Sensors (EmNets 2006), May 30-31 2006 ACM 1-59593-9/06/0005, Stanford
University, 2006.