=Paper=
{{Paper
|id=Vol-2694/paper5
|storemode=property
|title=A cloud-oriented architecture for the remote assessment
and follow-up of hospitalized patients
|pdfUrl=https://ceur-ws.org/Vol-2694/p5.pdf
|volume=Vol-2694
|authors=Salvatore Ivan Illari,Samuele Russo,Roberta Avanzato,Christian Napoli
|dblpUrl=https://dblp.org/rec/conf/system/IllariRAN20
}}
==A cloud-oriented architecture for the remote assessment
and follow-up of hospitalized patients==
https://ceur-ws.org/Vol-2694/p5.pdf
A cloud-oriented architecture for the remote assessment
and follow-up of hospitalized patients
Salvatore Ivan Illaria , Samuele Russob , Roberta Avanzatoc and Christian Napolid
a Fondazione Istituto Oncologico del Mediterraneo, Via Penninazzo 11, Viagrande 95029 CT, Italy
b Sapienza University of Rome, Piazzale Aldo Moro 5, Roma 00185 RM, Italy
c Department of Electrical, Electronic and Computer Engineering, University of Catania, 95125 Catania, Italy
d Department of Computer, Control, and Management Engineering, Sapienza University of Rome, Via Ariosto 25, Roma 00185 RM, Italy
Abstract
During the last months the dramatic COVID-19 outbreak has exposed the fragility of our healthcare system, as well as the
need for a smart remote follow-up system for the patients, in order to less the burden on the healthcare service and reduce
the average hospitalization time. In this paper we proposed a solution designed to grant maximum flexibility by means of
the allocation of resources on a cloud service for the remote follow-up of patients. Such resources can be used as a remote
support for the caregiver both when planning or enforcing a therapeutic path. A major explanation behind follow-up regards
the location and treatment of potentially adverse reactions after treatments. Physical side effects of the different modalities
of treatment might be various and crippling after chemotherapy and radiotherapy. Moreover remote follow up can be a
life-changing solution also on the economical side, due to the implication of therapeutic attendances for patients as far as
missed work and travel costs that must likewise be comprehended in the overall economical burden. In an investigation of
patients with testicular disease, Campbell et al. Finally such a solution could effectively improve the patient’s adherence to
the therapeutic plan. The ability to remotely follow follow-up is therefore a monetarily alluring choice as far as investment
funds, also given the improved efficiencies, reduced cost and number of missed working days for the patient. Patients with
a patient-held record may also take advantage of a more conscious and motivated interest over their own wellbeing, illness
and treatment, with a direct impact on patient’s adherence to the therapeutic plan.
Keywords
Cloud computing, Quality of service, Clinical management, Follow up, Psychological well-being
1. Introduction rect social distancing, involving their permanence as
well of their relatives, also avoiding gatherings, and,
During the last months the dramatic COVID-19 out- sometime, limiting the entrances in the ward. The ef-
break has exposed the fragility of our healthcare sys- fect of these necessary limitations is to increase the
tem. Moreover it gave use the possibility to rethink isolation effect on the hospitalized patient. Therefore,
different therapeutic procedures as well as cure proto- while the patient follows a cure protocol, he must also
cols. The activities of the healthcare operators in hos- be helped, with the same accuracy, by means of a par-
pital wards have been extensively remodeled, so as to allel protocol that takes care also of the solitude expe-
ensure greater safety for the entire staff operating in rienced by the person.
the facility as well as to enforce the required steriliza- Isolated patients are visited fewer times than non-
tion protocols to ensure the patients well being. The isolated patients, moreover such isolated patients gen-
hospital facilities had been required to enforce massive erally benefit of a shorter time span with their physi-
use of personal protective equipment, install sanitizing cians. Because of the significantly lower contact time
gel dispensers in every hallway and waiting room, de- observed, particularly among the most severely ill of
termine a maximum limit of people at the same time floor patients, a reexamination of the risk-benefit ratio
in the same room, and, above all to apply social dis- of this infection control method has been proposed. In
tancing. It follows that hospitalized patients have been facts the attending physicians are about half as likely
subjected to limitations, in order to maintain the cor- to examine patients in contact isolation compared with
patients not in contact isolation [1]. Similarly, other
SYSTEM 2020: Symposium for Young Scientists in Technology, studies have pointed out the concern that isolation may
Engineering and Mathematics, Online, May 20 2020
" salvatore.illari@fondazioneiom.it (S.I. Illari); negatively affect not only the perceived quality of ser-
samuelerussoct@gmail.com (S. Russo); vice but also the patients’ mental health [2, 3], with a
roberta.avanzato@phd.unict.it (R. Avanzato); substantial increase in anxiety and stress-related dis-
cnapoli@diag.uniroma1.it (C. Napoli)
orders [4, 5]. Finally [6] shows that isolation precau-
© 2020 Copyright for this paper by its authors. Use permitted under Creative tions are associated with adverse effects which may
Commons License Attribution 4.0 International (CC BY 4.0).
CEUR
Workshop
Proceedings
http://ceur-ws.org
ISSN 1613-0073 CEUR Workshop Proceedings (CEUR-WS.org) result in poorer hospital outcomes, a longer hospital-
CN CAS
CN
SU CN LN
SU TLN
SU LN
CLOUD
ONLINE ONLINE
SERVICE SERVICE
FRONTEND BACKEND
FRONTEND FRONTEND EDITING TECHNICAL
REMOTE REMOTE BACKEND BACKEND
CLIENT CLIENT
PATIENT’S CAREGIVER HEALTHCARE
TECHNICIAN
DATA (USER) SERVICE
(ADMIN)
(ADMIN)
Figure 1: A general schema of the system developed in this work. Clockwise: a representation of the cloud and its
resources, the administrative and test design backend, and, finally, the users’ frontend.
ization, an higher cost of care, as well as an higher rate update and management. The solution has been de-
of readmission to hospital within a month. signed to grant maximum flexibility allocating resour-
Differently from direct intervention, follow-up medi- ces on a cloud service. Such resources can be used as a
cine does not base its protocol only on drugs and pre- remote support for the caregiver both when planning
scriptions, on the contrary it build the intervention or enforcing a therapeutic path.
around the patient [7, 8, 9, 10]. Trough standardization The paper is organized as follows. After this brief
the caregivers are guided in making decisions regard- introduction, in the following Section 2 the designed
ing the more appropriate therapeutic plan for a spe- system is described in its constituent parts. In Sec-
cific conditions, while the medical practices can be ra- tion 3 we will focus on the management of the cloud
tionalized improving, in the end, the general outcome services giving further details on the resource alloca-
for the therapy at full advantage of the patient’s well tion policies. Finally in Section 4 we will draw our
being. Other fields of medicine can rely on very ef- conclusions.
fective clinical prediction rules in order to reduce the
uncertainty inherent the medical practice by defining
how to use clinical findings to make predictions [11]. 2. The developed system
Finally, it must be said that in certain cases it is ut-
In Figure 1 a gross schema of the designed system is
termost difficult to draw methodology-proof clinical
reported, this is composed by the following agents and
practice guidelines due to the extreme statistical and
components:
subjective variability of the matter at hand [12].
In the work presented on this paper we developed a label=. Frontend:
unified cloud-based resource for the management and • Online interface
execution of all the task related to the patient’s follow-
• Frontend remote clients
up from the creation of the medical record, to its use,
lbbel=. Backend:
30
USER
QOS HANDLER DISTRIBUTED DB
HTTP LOG
LSV SSL
caching HANDLER
Local
storage
DNS NAMESERVER
CLOUD VM
Apache
Local
Local Cluster
storage Slave
cache DB
CLOUD SERVICES
Job Main
Queque DB
Figure 2: Schematics of the services involved in developed system and the respective dependencies.
• Online interface 2.1. Frontend
• Administration backend The frontend of the system has been developed by mea-
• Technical backend ns of the Angular JS [13, 14] framework in order to
grant portability and compatibility with almost all the
lcbel=. Cloud
available hardware and software systems. In this man-
• Trusted Login Node (TLN) ner there are no particular requirements to interface
• Cloud administration service (CAS) with the developed system, granted the ability to exe-
cute JavaScript on a browser-like application. Although
• Login nodes (LN)
a web browser would have sufficed to interface with
• Computing nodes (CN) the online service, we developed a simple ad-hoc ap-
• Storage Units (SU) plication to oversimplify the interface. In this man-
ner it is possible to avoid unnecessary complication
The components are better described in the follow- for the caregivers that will benefit of this application.
ing. The frontend remote client only provides the interface
31
USER AMAZON LEX IOT RULE
AMAZON
AMAZON S3 AWS IOT CORE
API GATEWAY
AMAZON KINESIS AMAZON
DATA STREAM DYNAMO DB
AMAZON
POLY
AMAZON
AMAZON
DYNAMO DB
PINPOINT
STREAMS
INTERFACE CLOUD
Figure 3: The adopted Amazon Web Services (AWS) configuration and the relative data flow among the different compo-
nent and services within the cloud environment
.
APPLICATION APPLICATION
PROCESS
REQUEST CLOUD
HANDLER MANAGER
REQUIREMENTS EXECUTION
MONITOR
Figure 4: Schematics of the Cloud Administration Service (CAS).
for the final users, but it is not designed to create a new data, the the backend of the developed system provides
task or operate for its standardization, since these lat- the necessary support for the design of new task and
ter procedures are related with the backend. follow-up protocols as well as their standardization,
finally it implements the tools for the technical ad-
2.2. Backend ministration of the overall platform. Differently from
the frontend, the backend provides two separated con-
While the frontend for the proposed system is con- soles for caregivers and technicians. The first allows
stituted by the final interface that the users and pa- the caregiver to design a new task or protocol, insert
tients can use for the only purpose of entering certain the item, provide the validation rules, and request to
32
the system to analyze the validation data. The sec- Figure 3).
ond console is reserved for technical administration in The resource request is provided to the cloud man-
terms of resource allocation, cloud management poli- ager component which uses the Amazon AWS APIs to
cies, etc... effectively request the allocation of new virtual ma-
chines. The cloud manager interfaces with the AWS
2.3. Cloud IoT Core taking into consideration the AWS IoT rule
component that determine the policies for the Amazon
The cloud resources are allocated both for computa- Kinesis Data Stream. The Amazon Kinesis Data Stream
tional and provisional purposes. Complete standard- is a real-time streaming service that provides event-
ized procedures can be used and implemented by means driven messaging and supports extended microservice
of the frontend interface. In this case a simple set of architectures. This latter allows the processing requests
queries can do the job, by selecting and extracting the trough the Amazon API Gateway once an admin has
required data from the databases, distributed on sev- been logged and identified trough his credentials by
eral storage units (SU), as well as by uploading data for the Amazon Lex component to access the Amazon S3
further use. On the other hand the standardization of service.
a new test, due to the required statistical analysis, also In our system design also the database is distributed
makes use of the computing nodes (CN). The cloud sys- on the cloud and supported by the Amazon DynamoDB
tem is also provided with several login node in order services that allows data flow by means of the Ama-
to avoid direct interactions with the allocated comput- zon DynamoDb Streams component. Data transactions
ing nodes and storage units, excepted for the storage and session state are encrypted at-rest and securely
units containing the public database useful to run the managed in the high-performance and scalable NoSQL
fronted interface. Finally the technical administration datastore offered by DynamoDB.
of the cloud, due to the criticality of the matter, makes The Amazon DynamoDB Streams is also able to trig-
use of a trusted login node that ensure a grater security ger an AWS Lambda function in order to send notifica-
level. The details on the cloud policies are given in the tions, by means of the Amazon Pinpoint and Amazon
following Section 3. Polly services, to psychologist users when a patient
has completed a test, as well as to send notification
to a psychologist admin when the validation and stan-
3. The cloud environment dardization process advances or changes status.
In our proposal the cloud environment is administered
on a technical level by expert users. Moreover the sys- 4. Discussion and conclusion
tem has been studied in order to adapt to the total
load by allocating or freeing resources. For the im- In order to check the developed system on the field,
plementation we supported our system with the Ama- we simulated the small scale implementation on an
zon Web Services (AWS) [15], and particularly on the oncology ward of an hospital subjected to personnel
AWS ECS and S3 service [16]. The main component and visitors restriction due to an epidemic outbreak.
for the administration of the cloud environment is the In this scenario all members of the oncological staff
Cloud Administration Service (CAS) depicted in Fig- have to carry out certain activities, where possible,
ure 4. The Cloud Administration Service analyzes the in a smart working mode (e.g. the drafting of scien-
provided application and estimate the computational tific articles, end-of-treatment reports and other in-
burden by means of a XML application requirement ternal reports, statistical analysis and supplementary
descriptor. Along with the single application (e.g. a clinical reviews). While all the measures adopted in
meta-analysis by means of factorial analysis, multidi- such a scenario are necessary, as public health is al-
mensional scaling, etc...), the psychologist administra- ways at risk, these measures evidently dilute the ef-
tor also submits a set of requirements (e.g. the desired fectiveness of the treatment also remanding to the pa-
deadline or throughput, etc...). Both the application tient’s responsibilities to follow the planned path. In
descriptor and the submitted requirements, are then such a scenario the remote follow-up of patients be-
analyzed by the request handler module. The request came a mandatory measure to both enforce the neces-
handler has the responsibility to determine the correct sary sanitary safety protocols, as well as maintain an
allocation request mediating between the application high level of therapeutic quality in order to ensure the
requirements, the user defined constraints, and the ef- patients’ adherence to their therapeutic paths. In the
fective resource availability on the cloud system (see case study at hands, therefore, we propose to imple-
33
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