IEEE JOURNAL OF BIOMEDICAL AND HEALTH INFORMATICS, VOL. 1, NO.

00, 2013

WE-CARE: An Intelligent Mobile Telecardiology

System to Enable mHealth Applications
Anpeng Huang, Member, IEEE, Chao Chen, Student Member, IEEE, Kaigui Bian, Member, IEEE, Xiaohui Duan,
Min Chen, Hongqiao Gao, Chao Meng, Qian Zheng, Yingrui Zhang, Bingli Jiao, Member, IEEE,
and Linzhen Xie, Member, IEEE

Index TermsClinical trial, cardiovascular disease (CVD),

health risk monitoring, mobile health (mhealth), wearable efficient
telecardiology system(WE-CARE).

I. INTRODUCTION
HE cardiovascular disease (CVD) has become the leading
cause of human deaths, counting up to 29% of the total
global deaths, based on the WHOs The World Health Report
2008 [1]. The main symptoms of cardiovascular disease include
serious myocardial ischemia (acute myocardial infarction), heart
failure, malignant arrhythmia, etc. As shown in [2], most of
these symptoms can be foreknown by observing certain specific
manifestations of electrocardiogram (ECG) signals. The ECG
monitoring system has been used to detect such manifestations,
and early detection can save valuable time for taking precautions against the cardiovascular disease. Thus, the prevention of
cardiovascular disease using mobile ECG monitoring systems is
of paramount significance, which has garnered great attentions
from the research community.
The implementation of an efficient cardiovascular disease
prevention system requires tremendous medical resources. Early
alarm and medical instructions can be provided upon the detection of early signs of the disease or disease progression [3]. The
disease progression can be avoided by improving lifestyle, and
monitoring physiology parameters of out-hospital-patients [4].
However, it is difficult to implement a long-term monitor for
each outpatient or home user due to limited medical resources.
Recent advances in wireless mobile networking technologies
have provided an opportunity to alleviate this problem; this
concept is known as mobile health (mHealth) [5][8], which is
changing the way of health-care delivery today and hence, is at
the core of responsive health systems [9].
In this paper, we present WE-CARE, a Wearable Efficient
teleCARdiology systEm, that can provide 24/7 health monitoring service with the help of wearable and mobile 7-lead ECG
device.1 The use of five ECG electrodes helps collecting sufficient 7-lead ECG data to guarantee the detection accuracy without impairing the mobility of the system. More importantly,
WE-CARE employs a two-step approach that distributes the
detection task to both the mobile device and the server such
that the diagnosis capability of ECG devices can be exploited,

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AbstractRecently, cardiovascular disease (CVD) has become

one of the leading death causes worldwide, and it contributes to
41% of all deaths each year in China. This disease incurs a cost
of more than 400 billion US dollars in China on the healthcare
expenditures and lost productivity during the past ten years. It has
been shown that the CVD can be effectively prevented by an interdisciplinary approach that leverages the technology development
in both IT and electrocardiogram (ECG) fields. In this paper, we
present WE-CARE, an intelligent telecardiology system using mobile 7-lead ECG devices. Because of its improved mobility result
from wearable and mobile ECG devices, the WE-CARE system
has a wider variety of applications than existing resting ECG systems that reside in hospitals. Meanwhile, it meets the requirement
of dynamic ECG systems for mobile users in terms of the detection
accuracy and latency. We carried out clinical trials by deploying
the WE-CARE systems at Peking University Hospital. The clinical
results clearly showed that our solution achieves a high detection
rate of over 95% against common types of anomalies in ECG, while
it only incurs a small detection latency around one second, both of
which meet the criteria of real-time medical diagnosis. As demonstrated by the clinical results, the WE-CARE system is a useful
and efficient mHealth (mobile health) tool for the cardiovascular
disease diagnosis and treatment in medical platforms.

Manuscript received December 19, 2012; revised May 27, 2013; August
4, 2013; accepted August 13, 2013. Date of publication; date of current version. This work was supported in part by the National Science and Technology Major Projects in Wireless Mobile Healthcare Projects under Contracts
2012ZX03005013 and Contract 2013ZX03005008, and in part by the Okawa
Foundation. This paper was presented in part at the IEEE ICC 2013 conference.
A. Huang is with the Mobile Health Lab, PKU-UCLA Joint Research Institute, the State Key Lab of Advanced Optical Communication Systems and
Networks, and also with the Center for Wireless Communication and Signal Processing, Peking University, Beijing 100871, China (e-mail: hapku@pku.edu.cn).
C. Chen, M. Chen, H. Gao, C. Meng, Q. Zheng, and Y. Zhang are
with the Mobile Health Lab, Peking University, Beijing 100871, China (email: chao.chen@pku.edu.cn; chenmin7571@pku.edu.cn; hongqiaogao@pku.
edu.cn; pkumengchao@gmail.com; qianzheng@pku.edu.cn; yingrui_zhang@
pku.edu.cn).
K. Bian is with the Institute of Network Computing and Information System,
Peking University, Beijing 100871, China (e-mail: bkg@pku.edu.cn).
X. Duan is with the Mobile Health Lab and also with the Center for Wireless Communication and Signal Processing, Peking University, Beijing 100871,
China (e-mail: duan@pku.edu.cn).
B. Jiao is with the Mobile Health Lab and also with the Center for Wireless Communication and Signal Processing, Peking University, Beijing 100871,
China (e-mail: jiaobl@pku.edu.cn).
L. Xie is with the Mobile Health Lab, and also with the State Key Lab of
Advanced Optical Communication Systems and Networks, Peking University,
Beijing 100871, China (e-mail: tydxlz@pku.eu.cn).
Color versions of one or more of the figures in this paper are available online
at http://ieeexplore.ieee.org.
Digital Object Identifier 10.1109/JBHI.2013.2279136

1 The WE-CARE system has passed the test of Pharmaceutical Industry Standards of China: Electrocardiographic Monitors, YY 1079-2008, GB9706.12007, and GB9706.25-2005.

2168-2194 2013 IEEE

IEEE JOURNAL OF BIOMEDICAL AND HEALTH INFORMATICS, VOL. 1, NO. 00, 2013

Fig. 1. System Architecture. At the sensing layer, WE-CARE device collects

the raw physiological parameter (ECG), and completes the task of QRS complex
detection. At the network layer, the ECG data collected and alerts generated at
the sensing layer are transmitted to the data center. At the application layer,
WE-CARE server completes the computing-intensive task (T wave detection),
and generates alerts if necessary; physicians get access to the alert and ECG
data to perform further in-depth diagnosis.

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thereby reducing the length of the feedback cycle. Specifically,

automatic ECG analysis algorithms are introduced to detect
anomalies in ECG data, which can help significantly reduce the
time physicians spend in checking users ECG by 75% according to our clinical results.
For better understanding, the significance of WE-CARE system in this study, let us look at existing systems first. So far, the
existing 1-lead or 3-lead wireless ECG systems are for home
care users, in which the collected data are only for reference,
and lack necessary clinical values [8]. In hospitals, 12-lead or
18-lead systems are typically used but lack user mobility [10].
It is desired to design a system that combines user mobility
and intelligent clinical function with heath-risk alert [11]. Motivated by this trend, the WE-CARE system is developed for
7-lead ECG real-time monitoring service over mobile networks
(please note, a wireless network may be not mobile, but a mobile
network must be wireless).
The rest of the paper is organized as follows. Section II briefly
describes the technical background. Section III introduces the
system architecture and the design of the ECG device. Section IV describes the ECG detection mechanism. The performance evaluation of the system is demonstrated in Section V,
and we conclude the paper in Section VI.
II. PRELIMINARIES AND RELATED WORK
A. Principles for Devising a Wireless ECG System

The wireless ECG system can significantly save the medical resources by remotely monitoring the cardiac status from
ECG. However, there are three requirements for devising such
a system.
1) Support of mobile and wireless ECG device: Remote ECG
monitoring is of vital importance to out-of-hospital patients who are exposed to a high rate of recurrence, and it
requires the support of mobile and wireless ECG devices.
2) Sufficient ECG data collection: Different cardiovascular
diseases may cause anomalies on different leads of ECG
[12], and thus a wireless ECG system has to collect the
ECG data as complete as possible to guarantee the accurate
detection and diagnosis of cardiovascular diseases.
3) A small cycle of updating ECG data: The early warning
mechanism in wireless ECG systems requires the realtime analysis of ECG signals. A small cycle of updating
the collected ECG data to the data center will guarantee the
real-time alerts if the early sign of cardiovascular disease
appears. As a result, the efficacy of a wireless ECG system
depends on the cycle length that the device updates the
ECG data.
The wireless ECG monitoring system with a large number
of leads [13] are only designed for clinical usage (e.g., the 12
leads system), which restricts the mobility of users that are
located outside the hospital. For enabling the out-of-hospital
ECG monitoring, many existing wireless ECG systems have
mobile ECG devices with only one or three leads [14][17].
However, the reduced number of leads limits the amount of ECG
data that can be collected in unit time, which further degrades
the performance of the real-time diagnosis and causes delay

to the early warning/treatment against cardiovascular diseases.

Moreover, the cycle of updating ECG data in existing dynamic
ECG systems used in hospitals are typically more than 24 h [18],
which is too long for providing the real-time ECG alerts.
Therefore, no existing wireless ECG systems (either those
for home use, clinical use, or those with Holter) can fully fulfill
the above design requirements. In this paper, we built 7-lead
wearable and mobile ECG devices into the telecardiology system that leverages the tradeoff between the mobility support
and the sufficient collection of ECG data. Meanwhile, our built
system can meet the design requirements for the feedback cycle
and response delay.
III. OVERVIEW OF WE-CARE

In this section, we present an overview of the WE-CARE system, which provides a 24/7 ECG monitoring service for patients
with cardiovascular diseases or people that may have potential
cardiovascular problems.
A. Architecture of WE-CARE

As illustrated in Fig. 1, the system consists of three components, namely, the mobile 7-lead ECG device, the ECG data
center, and the relay device.
The ECG device completes four ECG monitoring tasks: the
collection, processing, display, and transmission of ECG data.
The QRS and T-wave detection algorithms are implemented
at the data processing step to detect the heart rate and certain
abnormal phenomena of the ECG. Meanwhile, it transmits collected data to the data center for more complex diagnosis such
as data mining [19]. Note that the collected ECG data will be
stored locally in the TF card of the device, and then transmitted
to the data center via mobile networks (e.g., WCDMA or LTE-

HUANG et al.: WE-CARE: AN INTELLIGENT MOBILE TELECARDIOLOGY SYSTEM TO ENABLE mHEALTH APPLICATIONS

Advanced networks). As shown in Fig. 1, the five electrodes

(RA, LA, LL, C, and a reference electrode) in WE-CARE system collect 7-lead ECG information, namely, I, II, III, aVR,
aVL, aVF, and V1; and our detection algorithms are based on
the lead II. The clinicians are free to choose any other leads for
executing detection algorithms when necessary.
The data center works as a diagnosis platform for the doctors.
When the ECG data are uploaded, the agent program provides
doctors a real-time display of the ECG via the web server. From
the ECG database of the data center, the doctor is able to acquire
a history of an individual users heart healthiness status.
Next, we introduce the ECG device in more details.
Fig. 2.

PCB of the ECG device.

B. Operating Modes
2) The QRS complex detection algorithm is implemented at
the device side in order to locate the R wave and detect
the R wave anomalies. Only the ECG data regarding R
wave anomalies will be uploaded to the data center in the
efficient-monitoring mode.
3) On the server side, using the obtained locations of R waves,
a T wave detection algorithm is implemented to further
locate the ST segment and detect the ST anomalies.

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We have implemented three operating modes on the ECG

device.
1) In the conventional power-saving mode, the ECG device
continually collects the users ECG data, and stores it
locally on the device, without any automatic uploading
to the data center. The collected data will be delivered or
copied to the server of hospitals manually, and this mode
is adopted by most existing dynamic ECG systems.
2) In the real-time mode, the ECG device continually collects
the users ECG data, and then forward all of the real-time
collected data to the data center over mobile networks.
The doctors are able to check the real-time or historical
ECG data of a user via the web interface.
3) In the efficient monitoring mode, the ECG device continually collects the users ECG data, and only transmits parts
of the collected data to the data centeri.e., the 60-s-long
ECG per hour. Meanwhile, the ECG device performs a
local real-time diagnosis over all the collected data. If the
local diagnosis mechanism identifies a potential risk, or
if a manual alert is triggered by the user, the device will
increase the sample rate from 250 to 500 Hz for the 60-s
long ECG collected, and then send it to the data center.
The 60-s ECG data are obtained from 30 s before to 30 s
after the anomaly/manual alert point. As long as the data
center receives an alert, the doctor will be able to see the
alert at the earliest convenience, and take actions for more
in-depth diagnosis or even early treatment. Note that device exceptions such as lead-off and connection-failure
will also generate an alert.
C. ECG Detection Process

The diagnosis of cardiovascular diseases depends on the observation of ECG owing to its convenience, reliability, and noninvasiveness. Many factors are useful to reflect the cardiac activity and help the observation, such as the P, QRS and T waves,
ST segment, RR interval, and other parameters. The ECG detection process includes a denoising phase and two ECG detection
phases.
1) In general, denoising is a necessary step before processing
and analyzing the collected data to remove the noise in the
dataset.

D. ECG Device

1) Hardware System: The hardware modules of the mobile

ECG monitoring device are built on a printed circuit board
(PCB), as shown in Fig. 2. The core of the hardware system
is an ARM microprocessor STM 32, which is used as the micro controller unit (MCU) of the ECG device. It has abundant
peripheral resources to meet the requirements of ECG monitoring. The MCU controls various hardware modules/interfaces
to complete the four ECG monitoring tasks. For example, the
ECG data collection of ECG is implemented by the ECG data
ADS module via SPI bus. Note that the ECG lead wire is the
hardware interface for input while the mobile module is the
hardware interface for output.
The device measures 100 mm 50 mm 15 mm, weighs
about 200 g with a 1500 mAh Li-ion battery. Our clinical results
showed that the battery life of our device for one full charging
cycle is 6 h in the real-time mode, 72 h in power saving mode,
and 48 h in monitoring mode, respectively. More information of
the hardware can be found in [20].
2) Software System: The software system of the device is developed on the transplanted C/OS-II system. The task manager
has the highest priority and it manages all the four ECG monitoring tasks. The collected ECG data has to be delivered to several
output modules, such as the WCDMA/LTE-Advanced transmission module, the TF card slot, the LCD interface, etc. The data
transmission between on-device modules is implemented by the
interprocess communication mechanism of message queues.
E. Clinical Data Transmission Mechanism
The clinical use of WE-CARE has posed constraints on the latency and the error rate of clinical data transmission. To achieve

Fig. 3.

IEEE JOURNAL OF BIOMEDICAL AND HEALTH INFORMATICS, VOL. 1, NO. 00, 2013

Frame structure.

Fig. 4. Error Rate of Transmission in We-Care. RT: Retransmission, C:

Compression.

3) Transmission Efficiency: In order to evaluate the transmission efficiency of WE-CARE, we chose the transmission
error rate and the data compression ratio as the evaluation measures.
We calculated the number of data frames processed on each
device, and the number of data frames decompressed on the
server, and then derived the transmission error rate for device d
as follows:
Fl,d + Fe,d
d =
Fd

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these goals, we optimize the data transmission mechanism in

the following ways.
1) Data Compression and Data Frame Assembling at Transmitter: Before data transmission, we apply the Huffman encoding [21] and Run Length encoding (RLE) [22] methods to compress the ECG data collected by the device. Since these applied
encoding methods are lossless, this data compression process
will not affect the accuracy of the ECG data. The compressed
ECG data will be transmitted in data frames, and each frame
contains a 19-Byte-long frame header that specifies the unique
user ID, the serial number of the frame, CRC information, and
other control information. The frame structure is illustrated in
Fig. 3.
2) Data Frame Reassembling at Receiver: To recover the
ECG data, the receiver (i.e., the server) has to collect all of ECG
data frames that are error-free, and put them in order according to
the serial numbers. However, data frames may be lost during the
transmission process using mobile module over wireless links;
moreover, data frames may arrive at the receiver out-of-order.
Hence, WE-CARE employs the reception window technique to
address these problems.
Reception window: The server maintains a reception window
for each device that is uploading ECG data by allocating a
temporary reception cache of 512 KB for that device. The cache
is initialized as a 1-D array with array indexes corresponding to
the serial number of the data frames to be received. According
to our experimental statistics, a 512 KB cache is generally able
to cache the ECG data for half an hour.
Upon each data frame arrival, the frame header is parsed
and the CRC checksum is verified. The frame that passes the
verification is then recorded into the reception cache (the array)
based on its ID and serial number. The server will periodically
send out a retransmission request to the device regarding the
missing frames or frames that fail to pass the verification until
the number of retransmission requests reaches a limit. Generally,
in our system, the maximally allowed number of retransmission
requests is set to 5 for the ECG data without alert, and it is set
to 10 for the ECG data with alert.
The server decides to terminate the reception process in the
current reception window when the cache is fulfilled without
missing frames or when the number of retransmission requests
reaches its limit. Once the server terminates the current reception
process, it decompresses data frames in the cache, records the
decompressed into an ECG record file, inserts the file as a new
record entry into the database, and then flushes the reception
window.
Owing to the data compression and the reception window
techniques employed, the transmission latency and the rate of
frame loss can be significantly reduced.

where Fd denotes the number of frames processed at device d;

Fl,d and Fe,d denote the numbers of lost and error frames corresponding to the specific device d at the server side, respectively.
The experimental results of transmission error rate are given
in Fig. 4, which clearly show that the transmission error rates
are significantly reduced by our transmission mechanism.
The data compression ratio at the device side is defined as
r
CR = B
B c , where Br is the number of bytes of the raw data and
Bc is the number of bytes of the compressed data. According to
our experimental results, the average compression ratio is 5.98.
IV. ECG DETECTION MECHANISM OF WE-CARE

In this section, we describe the ECG detection mechanism

of WE-CARE, which includes a denoising scheme, two ECG
detection algorithms, and the anomaly detection strategies.
A. Denoising of the ECG Signal

Due to the presence of noise, the collected ECG data may

not be ready for display or readable for diagnosis, and thus
the preprocessing of the raw data is necessary. The ECG signal detected by body surface electrodes contains seven different
types of interference, including power-line interference, baseline drift, electrode contact noise, electrode polarization noise,
electromyogram signals, internal noise of amplifiers, and movement interference.
Among these sources of interference, the power-line interference near 50 Hz and its harmonics and the baseline drift below
0.7 Hz are the two most contributing ones, which significantly

HUANG et al.: WE-CARE: AN INTELLIGENT MOBILE TELECARDIOLOGY SYSTEM TO ENABLE mHEALTH APPLICATIONS

Fig. 5.

Performance of the denoising filter.

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degrade the detection accuracy of the QRS complex. In the phase

of preprocessing of ECG signals, we focused on the removal of
these two types of noises. Inspired by the filtering method proposed in [23], we combined a 50 Hz Notching Comb filter and
a 0.7 Hz FIR high-pass filter as our digital filter to eliminate the
two types of interference mentioned previously.
We applied our filtering method to an ECG dataset obtained
from the MIT-BH database, and performance of the filter is
shown in Fig. 5. The blue curve (i.e., the bottom line) represents
the originally collected signal coupled with the baseline drift
and other minor interference. The red curve (i.e., the upper line)
represents the output of the filter. By comparing the original
signal with the output, we can observe that the baseline drift
of the ECG signal are completely eliminated. Meanwhile, the
noise in the horizontal segment is significantly reduced, which
implies that the power-line interference is also removed.

B. QRS Complex Detection Algorithm

To determine the start and end points of the QRS waves, it

is necessary to obtain the accurate location of R wave. Many
algorithms have been used to locate the feature points of R
waves, including the slope method, the amplitude method, the
area method, etc. [24].
The QRS complex detection algorithm in the WE-CARE
system is based on the difference threshold arithmetic, which
combines multiple existing methods. To meet the requirement
of real-time ECG monitoring, a dynamic threshold adjustment
mechanism was implemented in the algorithm. Algorithm 1
shows the pseudocode, and we briefly explain the procedure
next.
1) First, the thresholds of slope and amplitude are initialized
as 60% of the highest values in the first-second ECG data
stream respectively.
2) Then, we choose a nonoverlapping time window (usually
set to three seconds in the WE-CARE system) that slides
along the stream.

3) For every collected data sample in the time window, the

ECG device has to complete the following two tasks.
a) Location of R waves: The ECG device concludes
that an R wave is detected, if the slope between
the ith and (i + 2)th points and the amplitude of
the ith point is equal or greater than their thresholds,
respectively. Then, we search forward from the point
until the first extreme point is detected and the R
peak is identified. We use the time stamp when
the data point is collected as the location of the R
wave.
b) Calculation of heart beat: According to two adjacent
R waves locations, the real-time heart rate can be
calculated and written back into the frame header of
the ECG data.
4) When the location of R wave is determined, we search
forward and backward for the first negative extreme point
that could help locate the Q and S peaks, respectively.
5) The threshold values will be adjusted dynamically. If the
highest value increases, the threshold will be updated to
60% of the maximum. If all points amplitude or slope
values in current time window are less than the current
threshold, the threshold value will be reduced by 20% until they reach the critical value. Both of the adjustment
percentages aforementioned are obtained from our experiments.
Anomaly detection regarding R wave detection: Based on the
results of R wave detection, the WE-CARE device is able to
complete the simple anomaly detection tasks, such as detection
against RR interval anomaly, R wave amplitude anomaly, heart
beat anomaly, etc. For example, the heart beat value can be

IEEE JOURNAL OF BIOMEDICAL AND HEALTH INFORMATICS, VOL. 1, NO. 00, 2013

obtained by calculating the interval between two R waves, which

is a useful tool to observe the symptom of ventricular fibrillation.
C. T Wave Detection Algorithm
The ECG device transmits the sampled ECG data stream that
piggybacks the location information of QRS complex to the data
center. The T wave detection is a computing-intensive task and
running at the server side to further analyze the uploaded ECG
data.
To locate the T wave, we need to figure out the location of the
J point first, which is the point where the QRS complex joins
the ST segment. We define d as the first-order difference of the
ECG signal, and the first zero-point after R wave is the S peak.
Then we search forward along the ECG data from the S peak
for the first peak point p and get its amplitude d[p]. Based on
the value, we define a threshold,
= d[p] k,

ventricular hypertrophy, or an indication of acute period of myocardial infarction.

A more detailed description of our T-wave detection algorithm is illustrated in [26].

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where k = 13 is an empirical constant calibrated by experiments.

The first point that is equivalent to the threshold is the J point.
Let LJ denote the obtained location of the J point, we define a
window (bw , ew ) as a function of the RR interval (RRI) value.
(bw , ew ) = (LJ , LJ + t RRI),

where t (0, 1) and it is adjusted according to the waveform.

In our proposed system, the detection of T wave is based on
the characteristics of wavelet transform coefficient modules in
the window. To ensure the detection rate of T wave, we have to
carefully select the characteristic scale.
Since the energy of the QRS complex is higher than that of
the T wave, the QRS complex affects the recognition of T wave.
To address this problem, we lower the QRS complex to the
base line such that the T wave can be highlighted. Then, we decompose the ECG signal with wavelet functions of Daubechies
(db) series. Via the five-layer-decomposition with Daubechies 4
(db4) wavelet, the T peak can be detected on the fifth scale and
the noise can be obviously restrained. Note that the db4 wavelet
is (2) (t) symmetric wavelet, and the T wave peak corresponds
to the extreme point of wavelet transform. The T wave detection
algorithm (see Algorithm 2) traverses all the extreme points in
the window including the false extreme points, and the extreme
point with the maximum amplitude of its corresponding original
signal is recognized as the T peak.
Moreover, inspired by Mallats theory [25], our T-wave algorithm is also implemented on board. The process of wavelet decomposition is achieved via a group of orthogonal digital filters,
which are employed to decrease the computational complexity
of the wavelet transform.
Anomaly detection regarding T wave detection: The results
of T wave detection obtained by the WE-CARE server are useful for detecting complex anomalies. For example, if the QTinterval (between Q and T peaks) is too wide, the WE-CARE
system will generate an alert regarding the myocardial ischemia
and myocardial damage. Similarly, the symptom of T-wave inversion is typically a sign of chronic myocardial ischemia, left

V. PERFORMANCE EVALUATION

In order to evaluate the performance and efficiency of the

WE-CARE system, we chose a total number of 84 users at
Peking University Hospital as experimental subjects, and the
diagnosis was based on ECG data acquired by other hospital
facilities (e.g., desktop ECG units).
A. Data Collection

Users participating in the experiment were required to wear

the ECG acquisition device for 24 h a day, and they were divided
into two groups. One group called the group of normal subjects
(NS) included users without cardiovascular disease detected.
The second group represented the set of users with cardiovascular disease (CVD). All the subjects were free to stay in or leave
the hospital. Generally, the WE-CARE system is designed for
24/7 daily health risk monitoring. In applications, the clinicians
would help users apply the electrodes and show them how to
use the system. A manual of instructions was also provided to
patients. To further evaluate the performance of our system, we
also carried out experiments based on the ECG data obtained
from the European ST-T Database (ESD).
When no anomaly was detected, 60-s long, 250 Hz sampling
rate, 7-lead ECG data were uploaded to server periodically.
When an anomaly was detected, the device uploads the data
that is obtained from 30-s before to 30-s after the anomaly
point, which is 60-s long, 7-lead ECG data with a sampling rate
of 500 Hz. In order to avoid the potential error caused by packet
loss during wireless communication, we backed up the last 24 h
data on the local device.

HUANG et al.: WE-CARE: AN INTELLIGENT MOBILE TELECARDIOLOGY SYSTEM TO ENABLE mHEALTH APPLICATIONS

Fig. 6. Evaluation of R Wave and T Wave Detection. FNR represents the false
negative rate, and FPR represents the false positive rate.

B. Error Rates

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To validate the performance of R wave detection algorithm

in our system, we compared all 48 ECG cases in MIT-BIH
Arrhythmia Database [27] whose QRS complex locations were
included with our detection results. As the MIT-BIH database
gave the beat counts for the first 5 min of each record and the
remainder of the record, we used the former part for validation.
The result is shown in Table I.
For the 18348 QRS complexes above, the QRS complex detection ratio is 99.3%, which shows an outstanding performance.
We also validated our algorithms on ECG data in European STT database [28] for R and ST detection performance, part of the
results are shown in Fig. 7, Tables II and III (Table III can be
also found in [26]).
As shown in the result, the T wave detection ratio of our
algorithm is 97.5%, which is an improvement while current Twave detecting ratio is no more than 95% [29]. Note that when
the ST segment is with unnegligible noises (e0405.dat from
ESD), the detection algorithm of WE-CARE is able to maintain
a detection rate over 95%.
In our experiments, the collected data by the ECG device
were also compared with physicians observation. As for data
from European ST-T Database, the results were compared with
the note files. These two types of data are of a length of 300 s.
We applied a similar approach to the performance evaluation
of T wave detection. We measured the error rate and missing
rate of T wave detection using the first 5 min of the record. The
results are shown in Fig. 6, and we observed that a detection rate
of 99.4% for R wave detection and that of 97.7% for T wave
detection.

C. Categorical Anomaly Detection

In this experiment, we mainly focused on five common categories of anomalies, as listed in Fig. 8. We compared the
detected proportion of anomalies by our method with the manual
test statistics.

Fig. 7. Results of R and ST detection performance for data in European ST-T

database. (a) No. e0103 record, (b) No. e0166 record, (c) No. e0405 record,
(d) No. e0607 record.

As shown in Fig. 8, our system yields a high anomaly detection rate in every category. This implies that physicians can simply focus on those ECG data samples that receive an anomaly
detection alert in most categories. As a result, it will save at
least 75% of time spent in anomaly judgment and localization
compared with manual check, which greatly improves the efficiency of the cardiology diagnosis system. However, specific
ECG anomalies such as ST segment elevation and depression
are difficult for wireless ECG system to automatically recognize,
which still require humans efforts to identify.

IEEE JOURNAL OF BIOMEDICAL AND HEALTH INFORMATICS, VOL. 1, NO. 00, 2013

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TABLE I
QRS DETECTION PERFORMANCE FOR ECG DATA IN MIT-BIH ARRHYTHMIA DATABASE

TABLE II
QRS DETECTION PERFORMANCE FOR ECG DATA IN EUROPEAN ST-T DATABASE

TABLE III
T WAVE DETECTION PERFORMANCE FOR ECG DATA IN EUROPEAN ST-T DATABASE

D. Response Delay
We synchronized the clocks of the data center server and the
device. Then, we calculated the response delay as the difference
between the time point when the ECG dataare collected by the
device and the time point when the server makes a decision
(e.g., generates an alert). Table IV shows the response delay

of four types of anomalies: heart rate anomaly (HR), lead off

(LO), data center connection failure (DCF), and manual alert
(MA). To evaluate the response delay under high-concurrency
environment, we also simulated a scenario where 1000 devices
uploaded ECG data at the same time, and used a real device to
validate the system performance. No increase of delay or other
system performance degradations were observed.

HUANG et al.: WE-CARE: AN INTELLIGENT MOBILE TELECARDIOLOGY SYSTEM TO ENABLE mHEALTH APPLICATIONS

VI. CONCLUSION
In this paper, we present WE-CARE, an intelligent telecardiology system over mobile wireless networks. The ECG detection mechanism of WE-CARE includes two algorithms that
guarantee a high detection rate for anomaliesa rate of 99.3%
for the QRS complex detection, and a rate of 97.7% for T
wave detectionaccording to the clinical trial results. In the
efficient-monitoring mode, the WE-CARE system saves the
medical resources in terms of communication bandwidth and
the time of physicians. Moreover, the WE-CARE system meets
the clinical requirements and can be applied to both inpatients
and outpatients, especially for the cardiovascular disease-prone
population. This study demonstrated that mHealth concept can
be turned into real applications with promising future. Our further research will focus on the detection against certain hardto-recognize anomalies such as the ST segment elevation and
depression.
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Fig. 8. Performance of detection algorithms in five categories of anomalies.

(1) Resting RR interval normal range is between 0.6 (100 bpm) and 1 s
(60 bpm), (2) T wave inversion is a feature of myocardial infarction and angina,
(3) Abnormally prolonged or shortened QT interval means a risk of developing
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TABLE IV
EVALUATION OF AVERAGE RESPONSE DELAY FOR ANOMALY DETECTION
(UNIT: SECOND)

TABLE V
COMPARISON OF EXISTING REMOTE ECG SYSTEMS WITH WE-CARE

In addition, we also made a comprehensive comparison

among the WE-CARE system and a number of other remote
ECG systems, and the results are shown in Table V. In general,
there is no any real clinical meaning when the number of leads
is less than seven. On the other hand, user mobility is limited if
the number of ECG electrodes is greater than five (which cross
over top-down body). Since the WE-CARE is devised for 24/7
daily public healthcare monitoring, collected data of which is
only used for medical assistant in clinical diagnosis, the 7-lead
solution is the tradeoff choice for considering a combination of
adequate clinical information collection and user mobility requirement. To our best knowledge, this is the first 7-lead mobile
ECG system which passed medical standard tests and got the
national medical equipment production license.

10

IEEE JOURNAL OF BIOMEDICAL AND HEALTH INFORMATICS, VOL. 1, NO. 00, 2013

Chao Chen (S13) received the B.S. degree from the School of Electronic Engineering and Computer Science at Peking University, Beijing, China, in July
2011. He is currently working toward the Graduate degree at Peking University.
His research interests include mobile health, clinical data mining, and machine learning.

Kaigui Bian (M11) received the Ph.D. degree in computer engineering from
Virginia Tech, Blacksburg, VA, USA in 2011.
He is currently an Assistant Professor in the School of EECS, Institute of Network Computing and Information Systems, Peking University, Beijing, China.
His research interests include mobile computing, cognitive radio networks, network security, and privacy.

Xiaohui Duan received the B.S. and M.S. degrees in electrical engineering
from Peking University, Beijing, China, in 1989 and 1992, respectively.
He is currently a Professor with the School of Electronics Engineering and
Computer Science, Peking University. His current research interests include
communication signal processing, biomedical signal processing, and sensor
system.

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[16] S. H. Liou, Y. H. Wu, Y. S. Syu, Y. L. Gong, H. C. Chen, and S.

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[26] Q. Zheng, C. Chen, Z. Li, A. Huang, B. Jiao, X. Duan, and L. Xie, A
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Conf. Intell. Sens., Sens. Netw. Inf. Process., Rio de Janerio, Brazil, Feb.
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[Online]. Available: http://www.lifewatch.com/upload/infocenter/info_
images/25012010232255@PN_BC00031_Rev03_CG7000DXBT.pdf
Anpeng Huang (M05) received the M.S. degree from the University of Electronic Science and Technology of China, Sichuan, China, in July 2000, and
the Ph.D. degree from Peking University, Beijing, China, in June 2003. From
May 2004 to January 2005, he was a Visiting Scholar at the University of Waterloo, Waterloo, ON, Canada. From February 2005 to March 2008, he was a
Postdoctoral Researcher in the Department of Computer Science at the University of California, Davis (UC Davis), CA, USA. Since November 2007, he has
been an Associate Professor in the state key lab of advanced optical communication systems and networks, wireless communications lab, and PKU-UCLA
joint research institute of Peking University (PKU), China. He has more than
40 journals and conference papers, is the holder of 36 patents and US pending
patents (with PCT application), the advisor of Best Student Paper Award winner at 2012 14th IEEE HEALTHCOM conference, and the founder of mobile
health lab in PKU. His research interest includes mobile health.

Min Chen photographs and biographies not available at the time of publication.

Hongqiao Gao photographs and biographies not available at the time of publication.

Chao Meng photographs and biographies not available at the time of publication.

Qian Zheng photographs and biographies not available at the time of publication.

Yingrui Zhang photographs and biographies not available at the time of publication.

Bingli Jiao (M05) received the B.S. and M.S. degrees from Peking University,
Beijing, China, in 1983 and 1988, respectively, and received the Ph.D. degree
from the University of Sarrbruecken, Saarbrucken, Germany, in 1995.
He became an Associate Professor and Professor with Peking University
in 1995 and 2000, respectively. His current interests include communication
theory and techniques and sensor design.

Linzhen Xie received the B.S. degree from Peking University, Beijing, China,
in 1963.
He was a Visiting Scholar at the Department of Electrical Engineering and
Computer Sciences, University of California, Berkeley, CA, USA, from 1980 to
1982. He has been a Professor at Peking University in China, since 1978. He is
the founder of the State Key Laboratory of Advanced Optical Communication
Systems and Networks at Peking University . One of his Ph.D. students was the
winner of 100 Distinguished Ph.D. Dissertations in China in 2000. He has
published more than 140 papers in journals and at conferences in these areas,
and is the holder of 21 patents. His research interests focus on optical network
and switching, optical waveguide technology, and wireless communications.

IEEE JOURNAL OF BIOMEDICAL AND HEALTH INFORMATICS, VOL. 1, NO. 00, 2013

WE-CARE: An Intelligent Mobile Telecardiology

System to Enable mHealth Applications
Anpeng Huang, Member, IEEE, Chao Chen, Student Member, IEEE, Kaigui Bian, Member, IEEE, Xiaohui Duan,
Min Chen, Hongqiao Gao, Chao Meng, Qian Zheng, Yingrui Zhang, Bingli Jiao, Member, IEEE,
and Linzhen Xie, Member, IEEE

Index TermsClinical trial, cardiovascular disease (CVD),

health risk monitoring, mobile health (mhealth), wearable efficient
telecardiology system(WE-CARE).

I. INTRODUCTION
HE cardiovascular disease (CVD) has become the leading
cause of human deaths, counting up to 29% of the total
global deaths, based on the WHOs The World Health Report
2008 [1]. The main symptoms of cardiovascular disease include
serious myocardial ischemia (acute myocardial infarction), heart
failure, malignant arrhythmia, etc. As shown in [2], most of
these symptoms can be foreknown by observing certain specific
manifestations of electrocardiogram (ECG) signals. The ECG
monitoring system has been used to detect such manifestations,
and early detection can save valuable time for taking precautions against the cardiovascular disease. Thus, the prevention of
cardiovascular disease using mobile ECG monitoring systems is
of paramount significance, which has garnered great attentions
from the research community.
The implementation of an efficient cardiovascular disease
prevention system requires tremendous medical resources. Early
alarm and medical instructions can be provided upon the detection of early signs of the disease or disease progression [3]. The
disease progression can be avoided by improving lifestyle, and
monitoring physiology parameters of out-hospital-patients [4].
However, it is difficult to implement a long-term monitor for
each outpatient or home user due to limited medical resources.
Recent advances in wireless mobile networking technologies
have provided an opportunity to alleviate this problem; this
concept is known as mobile health (mHealth) [5][8], which is
changing the way of health-care delivery today and hence, is at
the core of responsive health systems [9].
In this paper, we present WE-CARE, a Wearable Efficient
teleCARdiology systEm, that can provide 24/7 health monitoring service with the help of wearable and mobile 7-lead ECG
device.1 The use of five ECG electrodes helps collecting sufficient 7-lead ECG data to guarantee the detection accuracy without impairing the mobility of the system. More importantly,
WE-CARE employs a two-step approach that distributes the
detection task to both the mobile device and the server such
that the diagnosis capability of ECG devices can be exploited,

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AbstractRecently, cardiovascular disease (CVD) has become

one of the leading death causes worldwide, and it contributes to
41% of all deaths each year in China. This disease incurs a cost
of more than 400 billion US dollars in China on the healthcare
expenditures and lost productivity during the past ten years. It has
been shown that the CVD can be effectively prevented by an interdisciplinary approach that leverages the technology development
in both IT and electrocardiogram (ECG) fields. In this paper, we
present WE-CARE, an intelligent telecardiology system using mobile 7-lead ECG devices. Because of its improved mobility result
from wearable and mobile ECG devices, the WE-CARE system
has a wider variety of applications than existing resting ECG systems that reside in hospitals. Meanwhile, it meets the requirement
of dynamic ECG systems for mobile users in terms of the detection
accuracy and latency. We carried out clinical trials by deploying
the WE-CARE systems at Peking University Hospital. The clinical
results clearly showed that our solution achieves a high detection
rate of over 95% against common types of anomalies in ECG, while
it only incurs a small detection latency around one second, both of
which meet the criteria of real-time medical diagnosis. As demonstrated by the clinical results, the WE-CARE system is a useful
and efficient mHealth (mobile health) tool for the cardiovascular
disease diagnosis and treatment in medical platforms.

Manuscript received December 19, 2012; revised May 27, 2013; August
4, 2013; accepted August 13, 2013. Date of publication; date of current version. This work was supported in part by the National Science and Technology Major Projects in Wireless Mobile Healthcare Projects under Contracts
2012ZX03005013 and Contract 2013ZX03005008, and in part by the Okawa
Foundation. This paper was presented in part at the IEEE ICC 2013 conference.
A. Huang is with the Mobile Health Lab, PKU-UCLA Joint Research Institute, the State Key Lab of Advanced Optical Communication Systems and
Networks, and also with the Center for Wireless Communication and Signal Processing, Peking University, Beijing 100871, China (e-mail: hapku@pku.edu.cn).
C. Chen, M. Chen, H. Gao, C. Meng, Q. Zheng, and Y. Zhang are
with the Mobile Health Lab, Peking University, Beijing 100871, China (email: chao.chen@pku.edu.cn; chenmin7571@pku.edu.cn; hongqiaogao@pku.
edu.cn; pkumengchao@gmail.com; qianzheng@pku.edu.cn; yingrui_zhang@
pku.edu.cn).
K. Bian is with the Institute of Network Computing and Information System,
Peking University, Beijing 100871, China (e-mail: bkg@pku.edu.cn).
X. Duan is with the Mobile Health Lab and also with the Center for Wireless Communication and Signal Processing, Peking University, Beijing 100871,
China (e-mail: duan@pku.edu.cn).
B. Jiao is with the Mobile Health Lab and also with the Center for Wireless Communication and Signal Processing, Peking University, Beijing 100871,
China (e-mail: jiaobl@pku.edu.cn).
L. Xie is with the Mobile Health Lab, and also with the State Key Lab of
Advanced Optical Communication Systems and Networks, Peking University,
Beijing 100871, China (e-mail: tydxlz@pku.eu.cn).
Color versions of one or more of the figures in this paper are available online
at http://ieeexplore.ieee.org.
Digital Object Identifier 10.1109/JBHI.2013.2279136

1 The WE-CARE system has passed the test of Pharmaceutical Industry Standards of China: Electrocardiographic Monitors, YY 1079-2008, GB9706.12007, and GB9706.25-2005.

2168-2194 2013 IEEE

IEEE JOURNAL OF BIOMEDICAL AND HEALTH INFORMATICS, VOL. 1, NO. 00, 2013

Fig. 1. System Architecture. At the sensing layer, WE-CARE device collects

the raw physiological parameter (ECG), and completes the task of QRS complex
detection. At the network layer, the ECG data collected and alerts generated at
the sensing layer are transmitted to the data center. At the application layer,
WE-CARE server completes the computing-intensive task (T wave detection),
and generates alerts if necessary; physicians get access to the alert and ECG
data to perform further in-depth diagnosis.

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thereby reducing the length of the feedback cycle. Specifically,

automatic ECG analysis algorithms are introduced to detect
anomalies in ECG data, which can help significantly reduce the
time physicians spend in checking users ECG by 75% according to our clinical results.
For better understanding, the significance of WE-CARE system in this study, let us look at existing systems first. So far, the
existing 1-lead or 3-lead wireless ECG systems are for home
care users, in which the collected data are only for reference,
and lack necessary clinical values [8]. In hospitals, 12-lead or
18-lead systems are typically used but lack user mobility [10].
It is desired to design a system that combines user mobility
and intelligent clinical function with heath-risk alert [11]. Motivated by this trend, the WE-CARE system is developed for
7-lead ECG real-time monitoring service over mobile networks
(please note, a wireless network may be not mobile, but a mobile
network must be wireless).
The rest of the paper is organized as follows. Section II briefly
describes the technical background. Section III introduces the
system architecture and the design of the ECG device. Section IV describes the ECG detection mechanism. The performance evaluation of the system is demonstrated in Section V,
and we conclude the paper in Section VI.
II. PRELIMINARIES AND RELATED WORK
A. Principles for Devising a Wireless ECG System

The wireless ECG system can significantly save the medical resources by remotely monitoring the cardiac status from
ECG. However, there are three requirements for devising such
a system.
1) Support of mobile and wireless ECG device: Remote ECG
monitoring is of vital importance to out-of-hospital patients who are exposed to a high rate of recurrence, and it
requires the support of mobile and wireless ECG devices.
2) Sufficient ECG data collection: Different cardiovascular
diseases may cause anomalies on different leads of ECG
[12], and thus a wireless ECG system has to collect the
ECG data as complete as possible to guarantee the accurate
detection and diagnosis of cardiovascular diseases.
3) A small cycle of updating ECG data: The early warning
mechanism in wireless ECG systems requires the realtime analysis of ECG signals. A small cycle of updating
the collected ECG data to the data center will guarantee the
real-time alerts if the early sign of cardiovascular disease
appears. As a result, the efficacy of a wireless ECG system
depends on the cycle length that the device updates the
ECG data.
The wireless ECG monitoring system with a large number
of leads [13] are only designed for clinical usage (e.g., the 12
leads system), which restricts the mobility of users that are
located outside the hospital. For enabling the out-of-hospital
ECG monitoring, many existing wireless ECG systems have
mobile ECG devices with only one or three leads [14][17].
However, the reduced number of leads limits the amount of ECG
data that can be collected in unit time, which further degrades
the performance of the real-time diagnosis and causes delay

to the early warning/treatment against cardiovascular diseases.

Moreover, the cycle of updating ECG data in existing dynamic
ECG systems used in hospitals are typically more than 24 h [18],
which is too long for providing the real-time ECG alerts.
Therefore, no existing wireless ECG systems (either those
for home use, clinical use, or those with Holter) can fully fulfill
the above design requirements. In this paper, we built 7-lead
wearable and mobile ECG devices into the telecardiology system that leverages the tradeoff between the mobility support
and the sufficient collection of ECG data. Meanwhile, our built
system can meet the design requirements for the feedback cycle
and response delay.
III. OVERVIEW OF WE-CARE

In this section, we present an overview of the WE-CARE system, which provides a 24/7 ECG monitoring service for patients
with cardiovascular diseases or people that may have potential
cardiovascular problems.
A. Architecture of WE-CARE

As illustrated in Fig. 1, the system consists of three components, namely, the mobile 7-lead ECG device, the ECG data
center, and the relay device.
The ECG device completes four ECG monitoring tasks: the
collection, processing, display, and transmission of ECG data.
The QRS and T-wave detection algorithms are implemented
at the data processing step to detect the heart rate and certain
abnormal phenomena of the ECG. Meanwhile, it transmits collected data to the data center for more complex diagnosis such
as data mining [19]. Note that the collected ECG data will be
stored locally in the TF card of the device, and then transmitted
to the data center via mobile networks (e.g., WCDMA or LTE-

HUANG et al.: WE-CARE: AN INTELLIGENT MOBILE TELECARDIOLOGY SYSTEM TO ENABLE mHEALTH APPLICATIONS

Advanced networks). As shown in Fig. 1, the five electrodes

(RA, LA, LL, C, and a reference electrode) in WE-CARE system collect 7-lead ECG information, namely, I, II, III, aVR,
aVL, aVF, and V1; and our detection algorithms are based on
the lead II. The clinicians are free to choose any other leads for
executing detection algorithms when necessary.
The data center works as a diagnosis platform for the doctors.
When the ECG data are uploaded, the agent program provides
doctors a real-time display of the ECG via the web server. From
the ECG database of the data center, the doctor is able to acquire
a history of an individual users heart healthiness status.
Next, we introduce the ECG device in more details.
Fig. 2.

PCB of the ECG device.

B. Operating Modes
2) The QRS complex detection algorithm is implemented at
the device side in order to locate the R wave and detect
the R wave anomalies. Only the ECG data regarding R
wave anomalies will be uploaded to the data center in the
efficient-monitoring mode.
3) On the server side, using the obtained locations of R waves,
a T wave detection algorithm is implemented to further
locate the ST segment and detect the ST anomalies.

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We have implemented three operating modes on the ECG

device.
1) In the conventional power-saving mode, the ECG device
continually collects the users ECG data, and stores it
locally on the device, without any automatic uploading
to the data center. The collected data will be delivered or
copied to the server of hospitals manually, and this mode
is adopted by most existing dynamic ECG systems.
2) In the real-time mode, the ECG device continually collects
the users ECG data, and then forward all of the real-time
collected data to the data center over mobile networks.
The doctors are able to check the real-time or historical
ECG data of a user via the web interface.
3) In the efficient monitoring mode, the ECG device continually collects the users ECG data, and only transmits parts
of the collected data to the data centeri.e., the 60-s-long
ECG per hour. Meanwhile, the ECG device performs a
local real-time diagnosis over all the collected data. If the
local diagnosis mechanism identifies a potential risk, or
if a manual alert is triggered by the user, the device will
increase the sample rate from 250 to 500 Hz for the 60-s
long ECG collected, and then send it to the data center.
The 60-s ECG data are obtained from 30 s before to 30 s
after the anomaly/manual alert point. As long as the data
center receives an alert, the doctor will be able to see the
alert at the earliest convenience, and take actions for more
in-depth diagnosis or even early treatment. Note that device exceptions such as lead-off and connection-failure
will also generate an alert.
C. ECG Detection Process

The diagnosis of cardiovascular diseases depends on the observation of ECG owing to its convenience, reliability, and noninvasiveness. Many factors are useful to reflect the cardiac activity and help the observation, such as the P, QRS and T waves,
ST segment, RR interval, and other parameters. The ECG detection process includes a denoising phase and two ECG detection
phases.
1) In general, denoising is a necessary step before processing
and analyzing the collected data to remove the noise in the
dataset.

D. ECG Device

1) Hardware System: The hardware modules of the mobile

ECG monitoring device are built on a printed circuit board
(PCB), as shown in Fig. 2. The core of the hardware system
is an ARM microprocessor STM 32, which is used as the micro controller unit (MCU) of the ECG device. It has abundant
peripheral resources to meet the requirements of ECG monitoring. The MCU controls various hardware modules/interfaces
to complete the four ECG monitoring tasks. For example, the
ECG data collection of ECG is implemented by the ECG data
ADS module via SPI bus. Note that the ECG lead wire is the
hardware interface for input while the mobile module is the
hardware interface for output.
The device measures 100 mm 50 mm 15 mm, weighs
about 200 g with a 1500 mAh Li-ion battery. Our clinical results
showed that the battery life of our device for one full charging
cycle is 6 h in the real-time mode, 72 h in power saving mode,
and 48 h in monitoring mode, respectively. More information of
the hardware can be found in [20].
2) Software System: The software system of the device is developed on the transplanted C/OS-II system. The task manager
has the highest priority and it manages all the four ECG monitoring tasks. The collected ECG data has to be delivered to several
output modules, such as the WCDMA/LTE-Advanced transmission module, the TF card slot, the LCD interface, etc. The data
transmission between on-device modules is implemented by the
interprocess communication mechanism of message queues.
E. Clinical Data Transmission Mechanism
The clinical use of WE-CARE has posed constraints on the latency and the error rate of clinical data transmission. To achieve

Fig. 3.

IEEE JOURNAL OF BIOMEDICAL AND HEALTH INFORMATICS, VOL. 1, NO. 00, 2013

Frame structure.

Fig. 4. Error Rate of Transmission in We-Care. RT: Retransmission, C:

Compression.

3) Transmission Efficiency: In order to evaluate the transmission efficiency of WE-CARE, we chose the transmission
error rate and the data compression ratio as the evaluation measures.
We calculated the number of data frames processed on each
device, and the number of data frames decompressed on the
server, and then derived the transmission error rate for device d
as follows:
Fl,d + Fe,d
d =
Fd

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these goals, we optimize the data transmission mechanism in

the following ways.
1) Data Compression and Data Frame Assembling at Transmitter: Before data transmission, we apply the Huffman encoding [21] and Run Length encoding (RLE) [22] methods to compress the ECG data collected by the device. Since these applied
encoding methods are lossless, this data compression process
will not affect the accuracy of the ECG data. The compressed
ECG data will be transmitted in data frames, and each frame
contains a 19-Byte-long frame header that specifies the unique
user ID, the serial number of the frame, CRC information, and
other control information. The frame structure is illustrated in
Fig. 3.
2) Data Frame Reassembling at Receiver: To recover the
ECG data, the receiver (i.e., the server) has to collect all of ECG
data frames that are error-free, and put them in order according to
the serial numbers. However, data frames may be lost during the
transmission process using mobile module over wireless links;
moreover, data frames may arrive at the receiver out-of-order.
Hence, WE-CARE employs the reception window technique to
address these problems.
Reception window: The server maintains a reception window
for each device that is uploading ECG data by allocating a
temporary reception cache of 512 KB for that device. The cache
is initialized as a 1-D array with array indexes corresponding to
the serial number of the data frames to be received. According
to our experimental statistics, a 512 KB cache is generally able
to cache the ECG data for half an hour.
Upon each data frame arrival, the frame header is parsed
and the CRC checksum is verified. The frame that passes the
verification is then recorded into the reception cache (the array)
based on its ID and serial number. The server will periodically
send out a retransmission request to the device regarding the
missing frames or frames that fail to pass the verification until
the number of retransmission requests reaches a limit. Generally,
in our system, the maximally allowed number of retransmission
requests is set to 5 for the ECG data without alert, and it is set
to 10 for the ECG data with alert.
The server decides to terminate the reception process in the
current reception window when the cache is fulfilled without
missing frames or when the number of retransmission requests
reaches its limit. Once the server terminates the current reception
process, it decompresses data frames in the cache, records the
decompressed into an ECG record file, inserts the file as a new
record entry into the database, and then flushes the reception
window.
Owing to the data compression and the reception window
techniques employed, the transmission latency and the rate of
frame loss can be significantly reduced.

where Fd denotes the number of frames processed at device d;

Fl,d and Fe,d denote the numbers of lost and error frames corresponding to the specific device d at the server side, respectively.
The experimental results of transmission error rate are given
in Fig. 4, which clearly show that the transmission error rates
are significantly reduced by our transmission mechanism.
The data compression ratio at the device side is defined as
r
CR = B
B c , where Br is the number of bytes of the raw data and
Bc is the number of bytes of the compressed data. According to
our experimental results, the average compression ratio is 5.98.
IV. ECG DETECTION MECHANISM OF WE-CARE

In this section, we describe the ECG detection mechanism

of WE-CARE, which includes a denoising scheme, two ECG
detection algorithms, and the anomaly detection strategies.
A. Denoising of the ECG Signal

Due to the presence of noise, the collected ECG data may

not be ready for display or readable for diagnosis, and thus
the preprocessing of the raw data is necessary. The ECG signal detected by body surface electrodes contains seven different
types of interference, including power-line interference, baseline drift, electrode contact noise, electrode polarization noise,
electromyogram signals, internal noise of amplifiers, and movement interference.
Among these sources of interference, the power-line interference near 50 Hz and its harmonics and the baseline drift below
0.7 Hz are the two most contributing ones, which significantly

HUANG et al.: WE-CARE: AN INTELLIGENT MOBILE TELECARDIOLOGY SYSTEM TO ENABLE mHEALTH APPLICATIONS

Fig. 5.

Performance of the denoising filter.

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degrade the detection accuracy of the QRS complex. In the phase

of preprocessing of ECG signals, we focused on the removal of
these two types of noises. Inspired by the filtering method proposed in [23], we combined a 50 Hz Notching Comb filter and
a 0.7 Hz FIR high-pass filter as our digital filter to eliminate the
two types of interference mentioned previously.
We applied our filtering method to an ECG dataset obtained
from the MIT-BH database, and performance of the filter is
shown in Fig. 5. The blue curve (i.e., the bottom line) represents
the originally collected signal coupled with the baseline drift
and other minor interference. The red curve (i.e., the upper line)
represents the output of the filter. By comparing the original
signal with the output, we can observe that the baseline drift
of the ECG signal are completely eliminated. Meanwhile, the
noise in the horizontal segment is significantly reduced, which
implies that the power-line interference is also removed.

B. QRS Complex Detection Algorithm

To determine the start and end points of the QRS waves, it

is necessary to obtain the accurate location of R wave. Many
algorithms have been used to locate the feature points of R
waves, including the slope method, the amplitude method, the
area method, etc. [24].
The QRS complex detection algorithm in the WE-CARE
system is based on the difference threshold arithmetic, which
combines multiple existing methods. To meet the requirement
of real-time ECG monitoring, a dynamic threshold adjustment
mechanism was implemented in the algorithm. Algorithm 1
shows the pseudocode, and we briefly explain the procedure
next.
1) First, the thresholds of slope and amplitude are initialized
as 60% of the highest values in the first-second ECG data
stream respectively.
2) Then, we choose a nonoverlapping time window (usually
set to three seconds in the WE-CARE system) that slides
along the stream.

3) For every collected data sample in the time window, the

ECG device has to complete the following two tasks.
a) Location of R waves: The ECG device concludes
that an R wave is detected, if the slope between
the ith and (i + 2)th points and the amplitude of
the ith point is equal or greater than their thresholds,
respectively. Then, we search forward from the point
until the first extreme point is detected and the R
peak is identified. We use the time stamp when
the data point is collected as the location of the R
wave.
b) Calculation of heart beat: According to two adjacent
R waves locations, the real-time heart rate can be
calculated and written back into the frame header of
the ECG data.
4) When the location of R wave is determined, we search
forward and backward for the first negative extreme point
that could help locate the Q and S peaks, respectively.
5) The threshold values will be adjusted dynamically. If the
highest value increases, the threshold will be updated to
60% of the maximum. If all points amplitude or slope
values in current time window are less than the current
threshold, the threshold value will be reduced by 20% until they reach the critical value. Both of the adjustment
percentages aforementioned are obtained from our experiments.
Anomaly detection regarding R wave detection: Based on the
results of R wave detection, the WE-CARE device is able to
complete the simple anomaly detection tasks, such as detection
against RR interval anomaly, R wave amplitude anomaly, heart
beat anomaly, etc. For example, the heart beat value can be

IEEE JOURNAL OF BIOMEDICAL AND HEALTH INFORMATICS, VOL. 1, NO. 00, 2013

obtained by calculating the interval between two R waves, which

is a useful tool to observe the symptom of ventricular fibrillation.
C. T Wave Detection Algorithm
The ECG device transmits the sampled ECG data stream that
piggybacks the location information of QRS complex to the data
center. The T wave detection is a computing-intensive task and
running at the server side to further analyze the uploaded ECG
data.
To locate the T wave, we need to figure out the location of the
J point first, which is the point where the QRS complex joins
the ST segment. We define d as the first-order difference of the
ECG signal, and the first zero-point after R wave is the S peak.
Then we search forward along the ECG data from the S peak
for the first peak point p and get its amplitude d[p]. Based on
the value, we define a threshold,
= d[p] k,

ventricular hypertrophy, or an indication of acute period of myocardial infarction.

A more detailed description of our T-wave detection algorithm is illustrated in [26].

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where k = 13 is an empirical constant calibrated by experiments.

The first point that is equivalent to the threshold is the J point.
Let LJ denote the obtained location of the J point, we define a
window (bw , ew ) as a function of the RR interval (RRI) value.
(bw , ew ) = (LJ , LJ + t RRI),

where t (0, 1) and it is adjusted according to the waveform.

In our proposed system, the detection of T wave is based on
the characteristics of wavelet transform coefficient modules in
the window. To ensure the detection rate of T wave, we have to
carefully select the characteristic scale.
Since the energy of the QRS complex is higher than that of
the T wave, the QRS complex affects the recognition of T wave.
To address this problem, we lower the QRS complex to the
base line such that the T wave can be highlighted. Then, we decompose the ECG signal with wavelet functions of Daubechies
(db) series. Via the five-layer-decomposition with Daubechies 4
(db4) wavelet, the T peak can be detected on the fifth scale and
the noise can be obviously restrained. Note that the db4 wavelet
is (2) (t) symmetric wavelet, and the T wave peak corresponds
to the extreme point of wavelet transform. The T wave detection
algorithm (see Algorithm 2) traverses all the extreme points in
the window including the false extreme points, and the extreme
point with the maximum amplitude of its corresponding original
signal is recognized as the T peak.
Moreover, inspired by Mallats theory [25], our T-wave algorithm is also implemented on board. The process of wavelet decomposition is achieved via a group of orthogonal digital filters,
which are employed to decrease the computational complexity
of the wavelet transform.
Anomaly detection regarding T wave detection: The results
of T wave detection obtained by the WE-CARE server are useful for detecting complex anomalies. For example, if the QTinterval (between Q and T peaks) is too wide, the WE-CARE
system will generate an alert regarding the myocardial ischemia
and myocardial damage. Similarly, the symptom of T-wave inversion is typically a sign of chronic myocardial ischemia, left

V. PERFORMANCE EVALUATION

In order to evaluate the performance and efficiency of the

WE-CARE system, we chose a total number of 84 users at
Peking University Hospital as experimental subjects, and the
diagnosis was based on ECG data acquired by other hospital
facilities (e.g., desktop ECG units).
A. Data Collection

Users participating in the experiment were required to wear

the ECG acquisition device for 24 h a day, and they were divided
into two groups. One group called the group of normal subjects
(NS) included users without cardiovascular disease detected.
The second group represented the set of users with cardiovascular disease (CVD). All the subjects were free to stay in or leave
the hospital. Generally, the WE-CARE system is designed for
24/7 daily health risk monitoring. In applications, the clinicians
would help users apply the electrodes and show them how to
use the system. A manual of instructions was also provided to
patients. To further evaluate the performance of our system, we
also carried out experiments based on the ECG data obtained
from the European ST-T Database (ESD).
When no anomaly was detected, 60-s long, 250 Hz sampling
rate, 7-lead ECG data were uploaded to server periodically.
When an anomaly was detected, the device uploads the data
that is obtained from 30-s before to 30-s after the anomaly
point, which is 60-s long, 7-lead ECG data with a sampling rate
of 500 Hz. In order to avoid the potential error caused by packet
loss during wireless communication, we backed up the last 24 h
data on the local device.

HUANG et al.: WE-CARE: AN INTELLIGENT MOBILE TELECARDIOLOGY SYSTEM TO ENABLE mHEALTH APPLICATIONS

Fig. 6. Evaluation of R Wave and T Wave Detection. FNR represents the false
negative rate, and FPR represents the false positive rate.

B. Error Rates

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To validate the performance of R wave detection algorithm

in our system, we compared all 48 ECG cases in MIT-BIH
Arrhythmia Database [27] whose QRS complex locations were
included with our detection results. As the MIT-BIH database
gave the beat counts for the first 5 min of each record and the
remainder of the record, we used the former part for validation.
The result is shown in Table I.
For the 18348 QRS complexes above, the QRS complex detection ratio is 99.3%, which shows an outstanding performance.
We also validated our algorithms on ECG data in European STT database [28] for R and ST detection performance, part of the
results are shown in Fig. 7, Tables II and III (Table III can be
also found in [26]).
As shown in the result, the T wave detection ratio of our
algorithm is 97.5%, which is an improvement while current Twave detecting ratio is no more than 95% [29]. Note that when
the ST segment is with unnegligible noises (e0405.dat from
ESD), the detection algorithm of WE-CARE is able to maintain
a detection rate over 95%.
In our experiments, the collected data by the ECG device
were also compared with physicians observation. As for data
from European ST-T Database, the results were compared with
the note files. These two types of data are of a length of 300 s.
We applied a similar approach to the performance evaluation
of T wave detection. We measured the error rate and missing
rate of T wave detection using the first 5 min of the record. The
results are shown in Fig. 6, and we observed that a detection rate
of 99.4% for R wave detection and that of 97.7% for T wave
detection.

C. Categorical Anomaly Detection

In this experiment, we mainly focused on five common categories of anomalies, as listed in Fig. 8. We compared the
detected proportion of anomalies by our method with the manual
test statistics.

Fig. 7. Results of R and ST detection performance for data in European ST-T

database. (a) No. e0103 record, (b) No. e0166 record, (c) No. e0405 record,
(d) No. e0607 record.

As shown in Fig. 8, our system yields a high anomaly detection rate in every category. This implies that physicians can simply focus on those ECG data samples that receive an anomaly
detection alert in most categories. As a result, it will save at
least 75% of time spent in anomaly judgment and localization
compared with manual check, which greatly improves the efficiency of the cardiology diagnosis system. However, specific
ECG anomalies such as ST segment elevation and depression
are difficult for wireless ECG system to automatically recognize,
which still require humans efforts to identify.

IEEE JOURNAL OF BIOMEDICAL AND HEALTH INFORMATICS, VOL. 1, NO. 00, 2013

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TABLE I
QRS DETECTION PERFORMANCE FOR ECG DATA IN MIT-BIH ARRHYTHMIA DATABASE

TABLE II
QRS DETECTION PERFORMANCE FOR ECG DATA IN EUROPEAN ST-T DATABASE

TABLE III
T WAVE DETECTION PERFORMANCE FOR ECG DATA IN EUROPEAN ST-T DATABASE

D. Response Delay
We synchronized the clocks of the data center server and the
device. Then, we calculated the response delay as the difference
between the time point when the ECG dataare collected by the
device and the time point when the server makes a decision
(e.g., generates an alert). Table IV shows the response delay

of four types of anomalies: heart rate anomaly (HR), lead off

(LO), data center connection failure (DCF), and manual alert
(MA). To evaluate the response delay under high-concurrency
environment, we also simulated a scenario where 1000 devices
uploaded ECG data at the same time, and used a real device to
validate the system performance. No increase of delay or other
system performance degradations were observed.

HUANG et al.: WE-CARE: AN INTELLIGENT MOBILE TELECARDIOLOGY SYSTEM TO ENABLE mHEALTH APPLICATIONS

VI. CONCLUSION
In this paper, we present WE-CARE, an intelligent telecardiology system over mobile wireless networks. The ECG detection mechanism of WE-CARE includes two algorithms that
guarantee a high detection rate for anomaliesa rate of 99.3%
for the QRS complex detection, and a rate of 97.7% for T
wave detectionaccording to the clinical trial results. In the
efficient-monitoring mode, the WE-CARE system saves the
medical resources in terms of communication bandwidth and
the time of physicians. Moreover, the WE-CARE system meets
the clinical requirements and can be applied to both inpatients
and outpatients, especially for the cardiovascular disease-prone
population. This study demonstrated that mHealth concept can
be turned into real applications with promising future. Our further research will focus on the detection against certain hardto-recognize anomalies such as the ST segment elevation and
depression.
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Fig. 8. Performance of detection algorithms in five categories of anomalies.

(1) Resting RR interval normal range is between 0.6 (100 bpm) and 1 s
(60 bpm), (2) T wave inversion is a feature of myocardial infarction and angina,
(3) Abnormally prolonged or shortened QT interval means a risk of developing
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TABLE IV
EVALUATION OF AVERAGE RESPONSE DELAY FOR ANOMALY DETECTION
(UNIT: SECOND)

TABLE V
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In addition, we also made a comprehensive comparison

among the WE-CARE system and a number of other remote
ECG systems, and the results are shown in Table V. In general,
there is no any real clinical meaning when the number of leads
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daily public healthcare monitoring, collected data of which is
only used for medical assistant in clinical diagnosis, the 7-lead
solution is the tradeoff choice for considering a combination of
adequate clinical information collection and user mobility requirement. To our best knowledge, this is the first 7-lead mobile
ECG system which passed medical standard tests and got the
national medical equipment production license.

10

IEEE JOURNAL OF BIOMEDICAL AND HEALTH INFORMATICS, VOL. 1, NO. 00, 2013

Chao Chen (S13) received the B.S. degree from the School of Electronic Engineering and Computer Science at Peking University, Beijing, China, in July
2011. He is currently working toward the Graduate degree at Peking University.
His research interests include mobile health, clinical data mining, and machine learning.

Kaigui Bian (M11) received the Ph.D. degree in computer engineering from
Virginia Tech, Blacksburg, VA, USA in 2011.
He is currently an Assistant Professor in the School of EECS, Institute of Network Computing and Information Systems, Peking University, Beijing, China.
His research interests include mobile computing, cognitive radio networks, network security, and privacy.

Xiaohui Duan received the B.S. and M.S. degrees in electrical engineering
from Peking University, Beijing, China, in 1989 and 1992, respectively.
He is currently a Professor with the School of Electronics Engineering and
Computer Science, Peking University. His current research interests include
communication signal processing, biomedical signal processing, and sensor
system.

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Anpeng Huang (M05) received the M.S. degree from the University of Electronic Science and Technology of China, Sichuan, China, in July 2000, and
the Ph.D. degree from Peking University, Beijing, China, in June 2003. From
May 2004 to January 2005, he was a Visiting Scholar at the University of Waterloo, Waterloo, ON, Canada. From February 2005 to March 2008, he was a
Postdoctoral Researcher in the Department of Computer Science at the University of California, Davis (UC Davis), CA, USA. Since November 2007, he has
been an Associate Professor in the state key lab of advanced optical communication systems and networks, wireless communications lab, and PKU-UCLA
joint research institute of Peking University (PKU), China. He has more than
40 journals and conference papers, is the holder of 36 patents and US pending
patents (with PCT application), the advisor of Best Student Paper Award winner at 2012 14th IEEE HEALTHCOM conference, and the founder of mobile
health lab in PKU. His research interest includes mobile health.

Min Chen photographs and biographies not available at the time of publication.

Hongqiao Gao photographs and biographies not available at the time of publication.

Chao Meng photographs and biographies not available at the time of publication.

Qian Zheng photographs and biographies not available at the time of publication.

Yingrui Zhang photographs and biographies not available at the time of publication.

Bingli Jiao (M05) received the B.S. and M.S. degrees from Peking University,
Beijing, China, in 1983 and 1988, respectively, and received the Ph.D. degree
from the University of Sarrbruecken, Saarbrucken, Germany, in 1995.
He became an Associate Professor and Professor with Peking University
in 1995 and 2000, respectively. His current interests include communication
theory and techniques and sensor design.

Linzhen Xie received the B.S. degree from Peking University, Beijing, China,
in 1963.
He was a Visiting Scholar at the Department of Electrical Engineering and
Computer Sciences, University of California, Berkeley, CA, USA, from 1980 to
1982. He has been a Professor at Peking University in China, since 1978. He is
the founder of the State Key Laboratory of Advanced Optical Communication
Systems and Networks at Peking University . One of his Ph.D. students was the
winner of 100 Distinguished Ph.D. Dissertations in China in 2000. He has
published more than 140 papers in journals and at conferences in these areas,
and is the holder of 21 patents. His research interests focus on optical network
and switching, optical waveguide technology, and wireless communications.