ASTER - Acute Stroke Care

Telematics for Ambulance Vehicles

Franziska Wolf

, Carsten Edelberger

and Thomas Wolf

Institut f. Automation und Kommunikation e.V. Magdeburg Werner-Heisenberg-Str. 1, 39106 Magdeburg, Germany

SBSK GmbH & Co. KG, Zackmünderstr. 4, 639218 Schönebeck-Elbe, Germany

Keywords: Networks in Vehicles, Secure Communication Systems, Medical Services, Stroke Care.

Abstract: In the collaboration project ASTER secure communication structures for ambulance vehicles are developed

in order to optimize care processes for paramedics in cases of stroke. Ambulance vehicles will be equipped

with various communication devices and technologies in order to enhance the care procedures in the pre-

clinical phase. IT-security and communication availability are the essential aspects of high-sensitive and

mobile communications developed for this case, because wireless transfer of sensitive data such as patient

and case related data will be involved. The structure and communication networks is designed and validated

using different scenarios of acute stroke care in order to answer the requirements towards the new

communication structure needed for security demands. In order to secure this high level data the project is

using certificated encrypted connections and a central communication node, which will be presented in

detail. The upcoming demonstrator of the ASTER project, a full applicable ambulance vehicle will be

equipped with the proposed technologies and systems in order to enhance the emergency procedures for

paramedics and patients suffering stroke.

1 INTRODUCTION

Stroke is one of the leading causes of death in

Germany, responsible for permanent disability and

dependencies (Heuschmann et al., 2010).

In 81% of strokes immediate medical

intervention can potentially offer a better success of

treatment. But for now only about 3% of all stroke

patens can benefit from this special treatment due to

a therapeutic timeslot of only about 4 hours after the

occurrence of symptoms. Furthermore special

diagnosis is required including CT scans of the head

by experienced doctors best performed in a stroke

specialist unit (stroke unit).

This is why especially rural regions such as the

north of Saxony-Anhalt suffer from the disastrous

consequences of strokes today. Because of the

demographic change it is expected that the direct

treatment costs will even rise, covering over 100

billion EUR in 2030 (Klebingat et al., 2010). An

acceleration of the procedures in cases of emergency

could increase this rate significantly, in all regions

(Kwon et al., 2008) As a consequence the

enhancement of preclinical emergency care

structures, especially for stroke patients are of

particular importance: Especially reliable detection

of strokes, a semi-automatic selection of the best

available hospitals and an early involvement of the

hospital staffs have a high potential of enhancing the

care procedures. The German research project

ASTER - Acute Stroke

care -Telematical platform for ambulance

vehicles - is a two year project which aims to

develop solutions for the optimization of stroke care

within the rescue chain. For this purpose a

communication platform is being developed,

connecting all kinds of stakeholders - ambulance

vehicles, control centres, paramedics, hospitals,

experts, external data sources such as traffic

information centres - to one another in order to

enhance the communication flow in the pre-clinical

field. The ambulance vehicle shall furthermore be

connected to traffic infrastructures e.g. for active

prioritisation at traffic light systems

(Kwon et al., 2008) and (Wolf et al., 2008).

Based on different radio standards, the information

exchange between target hospitals, paramedics and

other external data sources is designed to achieve

both: Optimal communication availability and IT-

security. In the following the actors of the ASTER

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Wolf F., Edelberger C. and Wolf T. (2013).

ASTER - Acute Stroke Care - Telematics for Ambulance Vehicles.

In Proceedings of the 10th International Conference on Informatics in Control, Automation and Robotics, pages 562-567

DOI: 10.5220/0004623305620567

 SciTePress

system are described along with the needed data

communication structures.

The use cases will lead to the functional

requirements derived. The concept of secure

communication architecture and its modules are

presented. Furthermore the design of the full

functional emergency vehicles which is currently

being equipped with all devices is shown.

1.1 Aims of the ASTER Project

The goal of the ASTER project is to develop a

telemedical platform for ambulance vehicles in order

to optimize the emergency care with the focus on

stroke emergencies.

The focus of the development is the

establishment of a digital mobile assistant for

paramedics (DIMAP), which assists the rescue staff

in order to enhance quality of diagnosis concerning

the type and severity of strokes. The DIMAP will be

used to collect data concerning patient and the

rescue case, to give assistance in choosing the best

hospital and in order to gain necessary support of a

stroke specialist in a stroke unit using a bi-

directional multimedia telemedical connection

(video conference). Here a camera and microphone

shall connect the paramedics on the case, which can

be the house or

flat of the patient or on-track during the trip to

the hospital, with the data sources they currently

need. The consultation of the expert can help in

various situations in order to assess the severity of

the stroke. Apart from the staff assistance the

DIMAP shall provide intelligent traffic telematics to

the ambulance vehicles in order to choose an

optimized route to the best hospital for the special

case of emergency. Factors of the different

accessible destinations like the occupancy rate,

specialization and availability of emergency rooms

and doctors will be taken into account. Then the

choice of route is actively made based on online

traffic data such as traffic, distances and further

more.

Active acceleration on-trip is realized by

activating a priority route through a sequence of

traffic lights (Pohlmann, 2010). These prioritisation-

routes are especially marked in the DIMAP in order

to choose the best route in order to assure the

optimal response time, one of the main optimisation

characteristics for operating procedures for

paramedics (Pons et al., 2005). The traffic telematics

module combines this information and generates a

route to the destination hospital optimized in way

and time for the diagnosed kind of emergency. Then,

the collected information is transmitted to the

destination hospital in order to make the necessary

preparations. The telemedical platform developed

for ambulance vehicles provides a link from mobile

emergency medical services to hospitals and

transport telematics. A practical use and a

comprehensive diagnosis will be possible wherever

needed. Therefore a real and full functional

ambulance vehicle will be equipped with different

modules of telematics as a prototype for

demonstrations and tests. The planned modular

design of the telemedical platform allows to be

extended for other emergencies such as heart attack

or polytrauma and highly integrates into the

workflows of other entities such as emergency

departments, emergency management and logistics.

2 ACTORS AND USE CASES

A use case defines the interactions between external

actors and the system under consideration to

accomplish a goal. The actors of the ASTER system

are mainly from the medical field. As stakeholders

they are interested in the enhancement of care

procedures, but not necessarily depending on such a

new system. Therefore the analysis of the current

working and caring procedures are essential in order

to integrate the ASTER system and it’s usage into

the normal working procedures of paramedics and

their infrastructure.

2.1 Actors of the ASTER System

The following actors interact with the ASTER

system:

Control Centre - it provides information on the

emergency situation and communication to the

paramedics via established radio systems (POCSAG,

etc.) and maintains contact to the hospitals and the

available emergency vehicles.

Paramedics and Ambulance - The paramedics

often are the first actors on the scene of emergency.

They are therefore the most important source of

information for the ASTER system. Here the data of

the case and the patients are collected.

The Medical Expert - The medical expert (stroke,

cardiac, trauma, etc.) is positioned in a specialised

hospital, such as a stroke unit. He or she provides

the paramedics medical and logistical help with a

video conference based of telemedical monitoring

stations.

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The Target Hospital - The target hospital and the

doctors on duty need information about the

emergency case of stroke and the initial diagnosis of

the patients arriving in the emergency room in order

to prepare the emergency rooms specifically.

2.2 Actors of the ASTER System

Figure 1: ASTER use cases.

According to the formally described actors

following use cases or applications are identified for

the ASTER system. Listed in chronological order

the following use cases of the Aster system are:

1. Case of Emergency - A case of emergency with

a suspected stroke occurs and the control centre

is informed. In the ASTER system potentially

applicable ambulances are displayed on a digital

map and appropriate notifications are given to

the ambulance vehicle and the paramedics using

the DIMAP.

2. Drive to the Scene of Emergency - The ASTER

system gives the optimal driving route to the

paramedics. This optimal route consists of

current traffic and route conditions. Furthermore

active prioritisations at traffic lights could lead to

an acceleration of the ambulance vehicle along

the res-cue route.

3. Intervention at the Scene of Emergency - It is

taken care of the and the relevant data such as

medical background of the patient and his/her

personal data is collected using a mobile device

the DIMAP. A specific decision support system

installed on the DIMAP enhances the estimation

of the severity of the stroke. If any doubts remain

a medical expert in a special stroke unit can be

consulted via a video conference.

4. Drive to the Best Hospital - Like the drive to

the scene of emergency the drive to the hospital

will be based on an optimized route. Furthermore

a prioritised selection of reachable hospitals will

be provided by the system, depending on the

hospitals current treatment capacities (available

doctors and CTs), specializations and current

journey times to the destination. When selected,

the emergency case and basic data of the patient

will be presented at the emergency room using

an arrival board.

5. At the Hospital - The patient is given to the

hospital staff. Through an automated data

transfer and authorization during the transport

the hospital is al-ready informed about the case.

6. Documentation - The processing of the case is

finished by the paramedics and the control

centre. The documentation and billing can be

done quickly based on digital, matched data.

According to the formally described actors

following use cases or applications are identified

for the ASTER system.

3 REQUIREMENTS OF

COMMUNICATIONS

ARCHITECTURE – DESIGN

OF A SECURE NETWORK

Each of the actors and use cases of the ASTER

system requires a specific data collection, processing

technology, and above all a secure data

communication. Especially the interoperability and

harmonization of the different data types, devices

and connections have to be integrated into existing

security concepts. Here, a continuous redundancy of

the infrastructure is necessary in order to provide an

availability of 99% or more.

Furthermore Aster has special requirements for

availability and reliability, particularly for the

mobile applications of ambulances on their way to

the scenes of emergency or the target hospitals.

Therefore the design has to involve dynamically the

best available connections such as GPRS, UMTS,

LTE, Wi-Fi and Ethernet.

A main interest of the Aster communication is

the secure transfer of particularly sensitive case-

related and personal data. They are classified as the

most sensitive data (Level E) of the Federal Office

for Information Security in Germany (BSI), because

they are directly linked to information about health,

life and economic existence of the patient, including

real name. Therefore, it is essential that this class of

data is only stored temporarily on the mobile devices

DIMAP in the ambulance vehicle. After completion

of the transport of the patient the data is immediately

archived, locked or freed of sensitive personal data.

A long-term storage of personal data shall not take

place on the DIMAP. The data communication itself

is to be certified. Therefore established encryption

protocols (IPSEC), primarily EAL 4 + certified

technology shall be used.

Furthermore the authentication of all users of the

ASTER system is set as mandatory. This is because

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of both: privacy reasons and for legal and liability

reasons.

4 IT SECURITY AND MOBILE

DATA COMMUNICATIONS

In order to answer the challenges of the

communication system and the system architecture

in ASTER concerning the mobile IT security

(Stumpf et al., 2007) a communication concept is

presented based on a centralized and scalable

instance. The developed system design is based on

the interaction of major functional blocks, their

spatial distribution and organization (hardware and

software units inside the ambulance vehicle and their

connections to the outside world) as well as basic

applications (including external data). Especially the

essential high security requirements are regarded

along the requirements of the BSI.

One of the basic requirements of security in the

project is the transmission restriction towards

sensitive or privacy relevant data which assures a

solely encrypted transmission in order to ensure the

end-to-end security within the communication

architecture. Because it is not feasible to distinguish

the different levels of sensitivity of the data during

the normal operational process, the general

encryption of all data is required. Therefore the

IPSEC protocol suite (Elkeelany et al., 2008) shall

be used for encryption, because it.

- transfers all IP packets

- is already certified in Router systems as

Common Criteria EAL 4 +

- provides strong encryption algorithms

- is already in use for similar applications in the

medical field,

- is a multi-vendor industry standard and

- is subject to a constant process of development.

4.1 The Central Communication Unit

Intermediary

An intermediary (Latin intermedius ”intermediary”)

is a mediating between the individual data sources

and subsystems of the ASTER system. The type of

placement can range from simple forwarding of IP

packets for individual services (e.g. voice and video)

over the caching of messages and data, to the

provision of supportive applications for paramedics

or other project partners. For the application to the

intermediary the requirements of the terms of

availability of the operation must be very high

(99.95%), also concerning the confidentiality and

privacy (category D + E BSI), same is true for the

software and hardware clients of the ambulance

vehicle. The system concept provides a strict

encapsulation of the data flows within the

intermediary and to the connected modules. Is can

be also used to for monitoring incoming and

outgoing data streams in real time in order to detect

attacks and viruses (IDS / IPS). The intermediary

and its communication structure is designed modular

and expandable and is based solely on currently

available device types and operating systems. Only

hardware and software components are considered

that are already certified according to Common

Criteria EAL4. The intermediary has to be stored in

a secure data centre providing a broadband internet

connection and the availability of official IP

addresses. The use of cloud technologies is possible,

providing that the strict protection of privacy and

confidentiality can be guaranteed, e.g. by having

already audited standards according to ISO27001 of

the BSI Protection Certificate.

Figure 2: The communications and modules of the

intermediary.

4.2 Basic Structure of the Intermediary

and the Communication Interfaces

The intermediary currently consists of the following

components:

– VPN: This VPN router performs the centralized

handling of all encrypted connections to all

ambulance clients and external data sources. It

also realizes the routing of data traffic (IP traffic)

from clients to external data and vice versa. The

VPN realizes the distribution of data streams

(routing), the implementation of IP addresses

(NAT) and the protection of security and

confidentiality. Furthermore, the individual

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network structures (such as private IP addresses)

of the connected partner and external data

sources will not be affected. The network traffic

from and to the intermediary is encapsulated by

the firewall rules restrictively configured and

verified by the proposed IDS / IPS functionality

permanently concerning malware and attacks.

– SEC: The security application handles the

authentication of users and the rights issues. In

addition, at the SEC component all the necessary

services are localized. This relates to the time

synchronization (NTP), the internal name

resolution (DNS), the self-monitoring (SNMP)

and logging (syslog) of the system components

of the intermediary.

– DATA: This component serves as data storage

and archiving. It thus provides a backup and

configuration management of the MDM (see

below) and for the provision of information of

navigation and traffic control systems.

– MDM Mobile Device Management: This

component implements the management of

mobile devices (e.g., configuration, maintenance,

backup, and update).With this component, the

operator is able to keep the mobile devices

available and secure. These include condition

monitoring Smart File Sync, File Push, backup,

restore, device management, software updates

and device localization (GPS). Necessary

maintenance actions are predictable and thus can

be realized automatically and unattended at

appropriate times.

– Central Hospital Node: It is to be examined in

the project, whether the existing functions of

hospital systems can be implemented in the

intermediary.

– VER: A Traffic Telematics Server, which

contains all the current traffic data and also the

communication with the light systems [11] can

be integrated via a secure connection or

alternatively installed as a separate instance.

The proposed communications architecture has been

designed based on the requirement analysis and the

use cases, focussing particularly on the security

requirements. A crucial factor was the seamless

communication of the backbone databases to time-

specific traffic data, clinic characteristics and stroke

characteristics in order to support all modules of the

ASTER-system: the software systems of the DIMAP

(medical and traffic modules) and the components of

the backbone systems. The goal of the overall

system design is a generic clinical supply

management, which opens the communication

components of emergency vehicles as preclinical

systems and passes through interfaces to hospitals,

centres and transport infrastructure. For every rescue

case, every control centre, every hospital and every

other external data source an encrypted connection

must be realised. For the external data sources, this

connection can be terminated on existing security

systems (firewalls and routers). Such a procedure is

already used widely by hospitals and industry

partners. But for the ambulance vehicles, the

connection must be held available as long it is

needed. This shall be automatically performed on

the best available internet technology (GSM, UMTS,

WLAN, etc.) using VIPRI net as an automatic

device.

5 SUMMARY AND FUTURE

STEPS

Each Stroke is the third leading cause of death in

Germany and often leads to permanent disability.

A quick consultation of experts on the case and

diagnosis of the patient based on his case data are

necessary to achieve rapid treatment and thus

recovery of the patient.

However, such time-optimized transportation

plans and treatment strategies are due to lacks of

communication infrastructures in the pre-clinical

environment.

Nevertheless they are essential in order to

improve chances of treatment, especially for stroke

patients. As the main objective of the project

ASTER a special secure IT communication

architecture has been set up in order to satisfy

various requirements of a mobile communication of

emergency vehicles on their way to the patients and

the hospitals.

Based on the requirements analysis and use cases

presented here, high secure communication

architecture has been realised. A crucial factor has

been the seamless communication of the backbone

databases (offering on-time traffic data; hospital

characteristics and stroke related knowledge to

support the decision support system) and the mobile

components of the emergency. This integrated

telematics platform will enable paramedics in the

future an accelerated, efficient and safe patient

transport.

For now the communication system is integrated

in a real ambulance vehicle with connection to the

intermediary. Therefore a cable and communication

plan has been set up, which will be built in till

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summer of 2013.

Figure 3: Communication infrastructures in the ambulance

vehicle demonstrator.

Other services that may be incorporated into the

ASTER system in future in order to expand the

medical rescue scenarios on other application

scenarios are:

– Chat / Instant Messaging application. The

implementation could be realized by a freeware

server in the intermediary. The protocol XMPP

protocol (Jabber) is favoured.

– Governikus. Optionally, the usability of certified

services (e.g. Gouvernikus) to the qualified

delivery of information is to be examined. This

service is based on the OSCI protocol. The aim

of the overall system design is the design of a

generic pre-clinical supply management, which

opens the communications components of

emergency vehicles as a preclinical system via

interfaces to hospitals, command centres and

transport infrastructure. The sentence must end

with a period.

ACKNOWLEDGEMENTS

The authors would like to express their

acknowledgement to the German Federal ministry

for Education and Research (BMBF) for granting the

national ASTER under the code 03WKP20F. The

results of which contributed to this paper.

If any, should be placed before the references

section without numbering.

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