Design and Implementation of a Tele-medicine Groupware

Design and Implementation of a Tele-
medicine Groupware to control a robot-
arm Telepointer to be used in Medical
Applications
A Master Thesis
Deepalakshmi Babu Venkateswaran,
2/8/2016
Supervised by:
Dr-Ing. Stefan Werner
Prof. Dr-Ing. Axel Hunger
Fakultät für Ingenieurwissenschaften
Fachgebiet Technische Informatik
Universität Duisburg-Essen

Design and Implementation of a Tele-medicine Groupware to control a robot-
arm Telepointer to be used in Medical Applications
1
ABSTRACT
Catering to the medical needs of people all over the world has been a constant
disappointment and the World health organization (WHO) decided that it
should no longer be the case in the 21st century in their health-for-all strategy
[1]. The major problem with equitable access to health care across the globe is
the requirement that both patients and doctors should be present at the same
location. Telemedicine provides unprecedented prospects for overcoming
these problems, by improving the quality and ease of access to the health care
systems. This paper examines the possibilities of providing medical solutions
for patients located physically away from the health care professionals. This
uses PASSENGER, a fully functional synchronous groupware system that was
developed at the Department of Computer Engineering, University of
Duisburg-Essen, as a conferencing system to facilitate seamless
communication[2]. Fast Remote Telepointer (FRT 500), a computer controlled
two-dimensional laser pointer is developed at the Department of Computer
Engineering, University of Duisburg Essen. The laser beamer distracted by
two mirrors produce a projection on the two dimensional surface, with the
use of which more accurate information or instructions can be sent in the form
of gestures which leads to more effective communication, precise diagnostics,
better decision making as a means of better communication and
communication between experts and junior clinicians [3]. The preliminary
results show that this application allows the participants to discuss some two
dimensional artifact together with the laser Telepointer located at a different
location. Audio and video communication channels are controlled using
different control strategies. The co-ordinates of the 2D images are scaled and
located as references. Architecture and distribution models are to discussed
and studied to describe different operational modes. The conclusion can be
drawn as, this application with a synchronous groupware and a Telepointer
can be used in remote and rural areas, where telemedicine would have a
greater impact, providing greater knowledge and enhanced communication
between the health care workers and all the more providing better diagnostic
and therapeutic services [4].

2
ACKNOWLEDGEMENT
It is my greatest pleasure to express my gratitude to people who made this
master thesis successful.
First of all, I would like to thank my supervisor, Dr-Ing. Stefan Werner for his
constant attention and interest in my thesis. He has been the greatest source of
encouragement during my master thesis. His comments and careful remarks
helped me to learn and execute better.
Furthermore, I would like to thank Prof. Dr-Ing. Axel Hunger for identifying
my interest and giving me a great opportunity to work on this master thesis
and much more. I would like to thank everyone in the department and it was
indeed an honor for me to work at the department of Computer Engineering.
Special thanks to Mr. Pascal Klein for helping me with Network protocols
when I was stuck in between, Dipl.-Ing. Joachim Zumbrägel for helping me
set up the passenger Server every now and then, and 'The Guys' Florian and
Stefan for helping me understand the working of the laser pointer initially.
Thanks to everyone who participated in testing of the groupware application.
I would also like to thank my parents and my sister for being supportive of all
my decisions. I’m deeply indebted to my friends who motivated me and
helped me while I was completely occupied with my master thesis. Without
my family and friends, I can’t imagine how this thesis would have been
possible.
Last but not least, I’m very thankful to the God Almighty for giving me the
strength and positive energy now and forever.

3
TABLE OF FIGURES
Figure 1-1 FRT 500 - Laser Pointer developed at the University oF Duisburg-
Essen ...................................................................................................................10
Figure 2-1Using Laser pointer to describe the affected areas.............................22
Figure 2-2Voltage convertor circuit. [3].................................................................25
Figure 2-3 WorkFlow of Teleradiology[30]...........................................................34
Figure 2-4 Telehealth monitoring[34].....................................................................35
Figure 2-5 Wireless Implantable devices [35] .......................................................36
Figure 3-1 Tele-medicine Scenario..........................................................................37
Figure 3-2 System Architecture...............................................................................38
Figure 3-3 Screen Shot of Remote Desktop Connection......................................39
Figure 3-4SSH Console of Putty..............................................................................40
Figure 3-5Overall design of the shared Workspace.............................................44
Figure 3-6Editor Panel..............................................................................................45
Figure 3-7 Editor Panel: Circle, Notation ..............................................................46
Figure 3-8 Editor Panel Free Form, overlay ..........................................................47
Figure 3-9Editor Pointer: Arrow.............................................................................47
Figure 3-10 Raspberry Pi camera module .............................................................50
Figure 3-11 Logitech C290 USB Webcam ..............................................................51

4
Figure 3-12 Passenger Communication components ..........................................53
Figure 3-13 moderator based floor control Scenario............................................54
Figure 4-2 Screenshot of Video Capture in the Telemedicine Application ......60
Figure 4-3Screenshot of the telemedicine tool......................................................60
Figure 4-4 Calibration Screen in Passenger...........................................................61
Figure 4-5 calibrated laser pointer..........................................................................62
Figure 4-6. GUI of Far end site 4.7 Near end with the Laser pointer ...............64
Figure 4-8Laser pointer and the user located at the Near end...........................65
Figure 4-9(Left) User at the far end site uses the tele-pointer application of
PASSENGER to control the FRT500 . (Right) Output of FRT500...............65

5
CONTENTS
CONTENTS ................................................................................................................5
1 INTRODUCTION..............................................................................................7
1.1 Background .........................................................................................................7
1.2 Motivation...........................................................................................................9
1.3 Goals...................................................................................................................11
1.4 Approach............................................................................................................12
2 THEORETICAL BACKGROUND AND PREVIOUS WORKS..............13
2.1 PASSENGER- A synchronous Groupware Application ..........................13
2.1.1 Groupware.................................................................................................14
2.1.1.1 Management of Shared Context .....................................................15
2.1.1.2 Concurrency Control........................................................................17
2.2 Input Devices....................................................................................................19
2.3 Fast Remote Telepointer FRT 500.................................................................23
2.3.1 Hardware and Server ...............................................................................24
2.3.2 Network and Data Protocol.....................................................................26
2.3.3 Calibration..................................................................................................29
2.3.4 CSCW in Health care................................................................................31
2.4 Tele-Medicine - An Overview.......................................................................32
2.4.1 Innovations in Telemedicine Technology .............................................34
3 OWN CONTRIBUTIONS FOR THE DEVELOPMENT OF A NEW
TELE-MEDICINE APPLICATION.......................................................................37

6
3.1 Overall Concept................................................................................................37
3.1.1 Tools & Programming languages used..................................................39
3.2 Graphical User Interface.................................................................................43
3.2.1 Components & Function..........................................................................44
3.2.3 Picture/ Video Capture ...........................................................................48
3.2.3.1 Camera................................................................................................49
3.3 Floor control & Communication Windows.................................................52
3.3.2 Communication Components.................................................................53
3.3.3 Moderator Based Floor Control ..............................................................54
3.4 Control of FRT-500...........................................................................................56
4 FIRST EVALUATIONS..................................................................................57
4.1 User Interface....................................................................................................58
4.2 Laser projections on 2D surface ....................................................................61
4.3 Test Results .......................................................................................................63
5 CONCLUSION AND OUTLOOK................................................................66
6 BIBLIOGRAPHY..............................................................................................68

7
1 INTRODUCTION
1.1 Background
Catering to the medical needs of people all over the world has been a constant
disappointment and the World health organization (WHO) decided that it
should no longer be the case in the 21st century in their health-for-all strategy
[1]. The major problem with equitable access to health care across the globe is
the requirement that both the patient and the doctor should be present at the
same location.
The transformation of the hospital from a leisure institution to a place of
hectic mass also happened slowly, over more than ten years. In 2000,
Germany had about 2242 acute care hospitals with almost 560,000 beds and
approximately 17 million patients. Since then, the number of hospitals has
decreased by ten percent, while the number of cases increased to a greater
extent. A patient is now only 7.7 days stationary, two days less than the
earlier days. These are the averages. In acute medical wards, the hospital
stays are much shorter, often only one or two nights. There were around half
a million outpatient surgery at German hospitals in 2002. Today there are four
times more, meaning less clinics are serving more patients in less time. And
they have the greater volume of work and document still considerably more
extensive. [5]
However, with recent developments in the field of information and
communication technologies, there are unprecedented prospects for
overcoming some of these problems.
Telemedicine, area where information and communication technology and
medicine meet is the major part of the revolution. Telemedicine can improve
the quality and ease of access to health care systems. [6] In remote and rural
areas telemedicine would have a greater impact, providing greater

8
knowledge and enhanced communication between the health care workers
and all the more providing better diagnostic and therapeutic services [7].
There are some telemedicine applications that exist in practice. Tele-stroke
networks is one such which has a comprehensive Center that acts as a hub
which is connected to the Rural hospitals and the Physician's homes. By using
this the consultants can communicate and with patients and doctors and
access camera to monitor patients and exchange data. This increases the speed
of treatment process, eliminates travel time and reduces the risk of stroke. [8]
Apart from this there are telemedicine treatments for oral health care in rural
areas of Japan [9], intensive care unit monitoring from RWTH Aachen
University [10], Telemedicine in Radiology [11]which are still in research.

9
1.2 Motivation
Today, most operational telemedicine services include tele-consultation in
over 30 specialties [7].
Distance treatment (Ed. Tele-surgery) and Tele-Education still remains a
subject of little practical experience and a lot of media interest. The little
practical experience is owing to the lack of the communication technologies
available in the earlier days. At present, with the improvement in internet and
digital communication progressively more researchers have started focusing
on Tele-Education and Distance treatments.
PASSENGER, Practical Training and Computer Supported Co-operative
Software Engineering is a synchronous groupware that was developed at the
University of Duisburg Essen throughout the last years. This synchronous
groupware is designed to support group-work and group-learning by using
different audio video communication components.[12] It originally supports
the scenario of software engineering education. With a research co-operation
with the University of Kebangsaan Malaysia, UKM, the National top research
University in Malaysia, this groupware shall now be redesigned for the usage
of Medical scenarios, like a teaching scenario between two university
hospitals in Éssen and Cheras. As a part of this co-operation, a hardware has
been developed that could serve as a telepointer that can projects objects at
one location and can be controlled from another location.
Given that, telepointers have a big influence on telemedicine technology, it
can improve the quality of health care especially in the rural area. With the
use of Telepointers more accurate information or instructions can be sent in
the form of gestures which leads to more effective communication, precise
diagnostics, better decision making as a means of better communication and
communication between experts and junior clinicians [13].

10
FIGURE 1-1 FRT 500 - LASER POINTER DEVELOPED AT THE UNIVERSITY OF
DUISBURG-ESSEN
A Telepointer application that could point to the location the specialist is
referring to, or to point a location that needs to be surgically removed or
treated would be a great benefit. This could also be extended to encircle an
affected area or tumor and to precisely show the entire area.

11
1.3 Goals
Passenger, the synchronous groupware and FRT 500, the laser Telepointer are
two individual applications. A new concept should be developed to integrate
these two and it should be able to serve together as a telemedicine
application. This application should allow the participants who are located in
the Near End to discuss some two dimensional artifact together with the laser
Telepointer located at a Far End. Audio and video communication channels
should be controlled using different control strategies. The co-ordinates of the
2D images should be scaled and located as references. Architecture and
distribution models are to be discussed and studied to describe different
operational modes.

12
1.4 Approach
In the following chapters the design and implementation of the Telemedicine
Application of Passenger integrated with FRT500 is described.
Chapter two gives an overview on the theoretical background in the field of
Tele-medicine as well as the previous works that were done in the field of
telemedicine and also throws some light into the concepts and design of FRT
500 which is needed to understand the design and implementation decisions
that is discussed later in the next chapters.
Chapter three explains the design and implementation of this project starting
from the architecture of the developed telemedicine application, user interface
and remote control. It also enlightens my new ideas of tele medical
applications that are integrated into conferencing applications.
Chapter four shows the results and the initial test runs within the University
of Duisburg Essen. Chapter five elaborates on the outlook of this application
in the future and how this can be explored further. This chapter also
highlights the possibility of telemedicine to become the trend in the future.

13
2 THEORETICAL BACKGROUND AND
PREVIOUS WORKS
In this chapter we discuss the theoretical backgrounds of Groupware, CSCW,
Telepointers and Tele-medicine. We also discuss the innovations in the field
of telemedicine and existing services that tele-medicine offers.
2.1 PASSENGER- A synchronous Groupware
Application
The synchronous Groupware PASSENGER is a client server based
conferencing system. It supports Software Engineering Education scenario for
a group of up-to four members along with a tutor. It is a CSCW application
that supports group activities by using separate communication and co-
operation tools.
Passenger uses an architecture model based on NetMVC. The advantages of
using NetMVC model is its ability to allow private views. This model also has
the increased robustness with respect to network losses, short communication
time and reply time. [2]
The communication tools use different audio video channels to provide a
stable communication channel over the network. Co-operation is provided by
the shared workspace which has the improved features of What you See Is
What I See. These communication and Co-operation tools are located in the
Application Level, in the Architecture.

14
2.1.1 Groupware
Computer Supported Co-operative Work, CSCW is a generic term which combines
the understanding of the way people work in groups with the enabling technologies of
computer networking and associated hardware, software services and technologies.
[14]
CSCW refers to the theoretical foundation of how groups work and how the
technology could be implemented to enhance the team work and
collaboration and co-ordination among the group, whereas groupware refers
to the software applications supporting these concepts. Primary aspects of the
groupware should have the possibility to collaborate, communicate and co-
ordinate. Groupware can be defined as:
Computer based systems that support groups of people engaged in a common goal and
it provides an interface to the shared environment. [15]
Based on the time space taxonomy groupware can be classified into
synchronous and asynchronous groupware based on the time and location of
the users, which is usually described as a 2x2 matrix.

15
Place/Time Same Time Different Time
Same Place Face To Face
Interactions
Asynchronous
Interactions
Different Place Synchronous
Distributed
Interaction
Asynchronous
Distributed
Interaction
Table 2.1 Time Space Taxonomy [14]
2.1.1.1 Management of Shared Context
For groupware, it is important to have a multi user interface which presents
the objects that are shared and the progress of the group. Whiteboards have
been used traditionally as an interface, in face to face meetings. However,
they have some constraints in terms of limited space, difficulty to restructure
the data once provided, need to physically write and focus on the legibility.
Gradually, whiteboards are being replaced by groupware systems. Set of
objects which are viewed jointly by all the participants and has the ability to
be manipulated is the shared context. [16]
Shared context appears to be more important in case of a synchronous
groupware system, where all the users need to co-operate simultaneously and
also be aware of the fellow workers efforts. To achieve the so called real time
behavior, all the activities are propagated immediately. Nevertheless, the time

16
limits which define real time nature are determined by communication
technology and group protocol restrictions. A synchronous groupware
typically has short response time, short notification time, flexibility of group
discussions and some external communication channels. [17]
In groupware systems, shared context can be achieved by a concept called
‘WYSIWIS’ – What You See Is What I See and is often used with synchronous
groupware applications. WYSIWIS means that all the participant in a
synchronous groupware session has access to the same exact content. Only
public windows are used and any information is made available to all the
participants including the cursor movement and scrolling. As this strict form
could create troubles among the users when they start accessing different
parts of the screen or data, there is a modified form called relaxed WYSIWIS.
A relaxed WYSIWIS supports two aspects which makes it effective and
optimal. 1. Separation of workspaces. The major problems with strict
WYSIWIS can be overturned by using a separate private and public
workspace, where public workspace usually meets the requirements of
shared context, making information available to all the users for viewing and
manipulating, while the private window is where the users have their own
workspace. Transition between private and public windows must be available
at all times and should be seamless. 2. Cursor Display. Strict WYSIWIS
displays the cursor of 2 or more participants are at the same time, whereas the
relaxed form displays only the cursor of the private user. Cursor of other
participants should be made available upon request. [18]
In the Synchronous groupware PASSENGER, the management of shared
context is implemented by the shared workspace. It is modeled as 'Shared-
Whiteboard-Data-Model'. The whiteboard has private and public windows
where the participant can work on the scenario of software engineering
education. Private window is available for all online users and offline users
and the private window of the current floor holder is displayed on the public

17
window of all the online users of the current session. Further, a relaxed
WYSIWIS is employed in Passenger, which uses a Telepointer as a cursor
display. It is used to improve the collaboration services of the groupware.[2]
Telepointers can be used exclusively for pointing shared information in the
public space. Telepointers can be special cursors which can be used only by
one person at a time, which is naturally different from the private cursor
visually. Telepointers are positioned based on the information not on the
exact location. More about Telepointers are discussed in 2.3.
2.1.1.2 Concurrency Control
Concurrent manipulation of shared contents is one of the major requirements
of groupware systems, to resolve conflicts that may rise between the
participants and to keep the information consistent.
Concurrency control can be classified based on the consistency of the
information shared, optimistic and pessimistic, where optimistic does not
constrain the activities of all the participants. Pessimistic on the other hand is
classified again as centralized and decentralized. Centralized has two classes
of control schemes. Control Unit, where all the operations are serialized and
synchronized. However, it needs a primary sit from which all the information
is replicated. If the primary site fails there has to be a secondary site and so
on. The second scheme is token passing, which introduces a token for each
replicated file. The token travels along the virtual ring on the network.
Though it seems to work fine for smaller network rings, for larger rings, it
takes a lot of time and as a result it reduces simultaneous work.[19]
Decentralized control has simple locking schemes and floor passing schemes.
Floor passing schemes give permission to all the participants of the group.
Only one user has the control point at one point of time. The choice of
choosing the participant and the time limits describe the different floor

18
passing schemes. In Explicit floor passing, the current active user passes the
floor actively to the user requesting for the floor. The new user becomes the
floor owner, he now passes the floor to the other user requesting and so on.
With Implicit floor passing, there is more significance given to fairness
meaning if the current floor owner remains inactive for a described length of
time, the floor can be automatically be passed to the next user requesting for
the floor.[20]
Concurrency control is implemented in passenger by what is called
'Passenger-Floor-control-model'. Floor control mechanism controls access to
the shared resources and improves the fairness of floor passing. It has a 'Floor
-list' which contains all the users requesting for the rights. When the current
floor holder releases the floor the floor is automatically assigned to the first
person requested for rights.
Tutor is another role concept available in passenger. The tutor can interrupt
any participant at any time and possess the rights. There is also another
possibility for interruption in case of emergency called the intermediate call.
The floor holder can either accept the intermediate call or reject it. There are
different color codes for each roles to facilitate better group awareness. [2]

19
2.2 Input Devices
Telepointer technology could revolutionize the human gesture with computer
supported pointers including the multimedia content as much as possible as it
could also improve the user attention and increase the clarity of the
information provided. Telepointer is one of the features of CSCW, which
usually is a part of the setup including video display, a pointer device, a
computer and a camera. The local computer will also have a mode to point to
a particular object on the screen which needs to be synchronously pointed by
the action of remote Telepointer. The input device could be a mouse pointer
or a touch screen or hand gestures or even a wacom board. The comparison
between these input methods, their advantages and disadvantages are
mentioned in the table 2.2.

20
Input
Devices
Advantages Disadvantages
Mouse
pointer
• Cost effective
• No special knowledge or
practice is required
• High precision
• Visible cursor so that the
user is aware of what is
happening
• The hardware needs to be
additionally provided.
• Portability is less compared to
other devices
• Needs a flat space
Touch
screen
• Quick and intuitive
• Compact
• Durable
• Ease of access
• Smear on the screen
• Added thickness
• High cost
• Difficult to input large amount of
data
Hand
Gesture
• Using hand gesture for 3D
laser control would give
more nature feeling of
virtual environment
• Irrelevant objects might overlap
with the hand
• It is vulnerable to errors
• So many restrictions such as the
position of arm and hand, distance
to camera
• Still under research, so expensive
• Ambient lighting might affect the
detection threshold
Graphics
tablet
• It is very natural and easy
to draw diagrams using a
stylus.
• Accuracy could be perfect
• Very expensive
• Not easily portable
• Users need some specialized
knowledge on how to operate the
device
Table 2.2 Advantages and disadvantages of Telepointer input devices

21
There is a difficulty in pointing the Telepointer to the exact location in case of
relaxed WYSIWIS, because the users have the access to scroll the screen and
change in the windows in relaxed form and this could cause confusions in
mapping the pointer. This could be achieved without many problems by
having a 2 layered implementation where one layer has the Telepointer and
the other layer has all the other user information. There two layers can be
individually mapped based on the scrolling and changing of windows.
In case of users using different format of windows, the objects appear
differently, which requires the application to reformat the objects to fit the
space. This could be done at any level, however, there are some limitations on
the amount of space that could be occupied. Empty spaces or void spaces
without any objects could cause confusions if the pointers are mapped to the
objects. If hand gestures or pointer devices are used, discontinuities could
cause some jumps in the movements.[13]
There are several approaches to Telepointer also based on the input methods.
Cursor pointing, the simplest pointer which has a computer supported cursor
to point out the shared information to the other participants. The movement
of the cursor pointer could be controlled by a mouse pad or a touch pad from
another computer. Laser pointer has the advantage that it can point out to any
distance and it could be made visible. There are already three colors of laser
red, green and blue in the market with different wavelength ranges. Red,
obviously has the highest range and it is visible for a longer distance, hence it
is used often these days. Laser pointer could also be handled manually or
with computer support. Hand pointers of course used for hand gesture inputs
and uses typically a finger pointer. It is the most expensive and the most
recent form of pointer and it is still in early stages of development.
Telepointer technology is defined as “an interactive style for presentation
system, interactive television and other systems where the user is positioned
at a remote location from the display” [4]. The motion of the Telepointer

22
should represent the human gesture. Telepointers could be used to either
point to a region or an object of interest or to create a pattern to signify
something depending on movement, location or other information at the
remote display .
FIGURE 2-1USING LASER POINTER TO DESCRIBE THE AFFECTED AREAS

23
2.3 Fast Remote Telepointer FRT 500
Fast Remote Telepointer is a laser pointer which is computer controlled. The
pointer works with the help of two mirrors connected to servo motors, which
distracts the laser beam in the x and y axis correspondingly. This allows the
laser pointer to make a projection on a 2D surface.[3]
For the computer control of the laser pointer the data from the computer
needs to be transferred to the servo motors as signals to move according to
the user requirements. This requires the use of three major hardware
components. The first component is Data Acquisition system. DAS is
connected to the server through USB. This converts the digital signal received
into Analog voltage. This Analog voltage is then sent to the servo driver card
which converts the voltage into current signal. The voltage sent to this deriver
card is also a differential voltage. Which means a voltage of -10V means that
the motor is positioned completely to the left and +10 V means the motor is
positioned completely to the right. Servo Driver card, the second component
converts voltage into driver current according to the actual position of the
motor. As the laser pointer needs to be distracted in two directions, we have
two mirrors and two motors, we also require two servo driver card. There is a
necessity for heat sink to be mounted to the output stage transistors as this is
sensitive to overheating. The last is a scanner system or a Galvanometer,
which has high precision, fast motors and it can move the motors up to 15µs.
The time is increased or decreased by adjusting the distance between the dots,
at which the user wants the laser to draw.
The movement of the laser pointer could be described as a combination of
objects, coordinates and hidden lines. Co-ordinates are points, the data
structures which are joined together to form objects. However, the laser does
not draw just one point. It draws complex figures that require many co-
ordinates. Sending every co-ordinate is not the fastest solution so the objects

24
are define. Also, for each objects, the co-ordinates are repeated up to ten times
so that they are visible for the human eye.
It can be used for different applications. For example, it is possible to extend a
webcam chat system with the protocol for controlling the laser. In this case it
is also possible to show the conversational partner something at his own
location. Another example of application is the interactive assistance of
doctors, for example, when there is no qualified first aid personal, someone
could show how to carry out a procedure to help the patient.
2.3.1 Hardware and Server
The laser beamer can be operated by giving required commands to it via the
hardware components including an AVR micro controller and digital to
analog converters connected to the raspberry Pi which is the server.
Raspberry Pi is a small single board computer with a processing speed of 700
MHz developed by the Raspberry Pi Foundation. They provide Ethernet port
and can be connected via Local access network and also Wireless LAN. The
operating system of raspberry Pi is based on Linux- Kernel. However current
release of Ubuntu and other operating systems also support Raspberry Pi.
Raspian is also supported which is usually used for robotics projects with
Lego, Arduino etc. Some versions of Raspberry Pi also support additional SD
cards to be attached for memory. [21]
In FRT-500, the used server is raspberry Pi2 B along with (General Purpose
Input/Output) GPIO connector. GPIO connector is the feature of raspberry Pi
that allows to control devices, by acting as an Input output interface. GPIO
allows to send (Output) information and get (Input) data and commands.
There are different kinds of GPIO connectors, which differs on the basis of the
number of pins. E.g. 26 Pins GPIO, 40 Pins GPIO connectors [22]. FRT 500
uses 40 Pin GPIO connector which is usually used for Raspberry Pi 2 Model B.

25
The pins could be programmed as general output or as general input by using
them as switches, by giving High for On and Low for Off. A potential
difference of 3.3 V is provided when it is high.
It is also important to note that raspberry pi is not designed to supply power,
however only to provide data or information which is why we use separate
power supply systems and drivers to provide current signals to the servo
motors. The raspberry Pi also does not have inbuilt timers so there is also a
necessity to use micro controllers for this purpose.
The output of the raspberry pi which is a maximum 3.3V needs to be
converted into a maximum of 5V before sending that as an input to the
microcontroller. For this purpose, a converter circuit is employed. This
convertor circuit is designed as a combination of NPN transistors and
resistors. The figure 2.2 shows the circuit of this convertor.
For the movement of the laser, two 16 bit DACs are used. To get a smooth
output movement, this is sent through the low pass filter to remove any
additional noise. These signals should also be inverted, as the requirement is a
differential signal.
FIGURE 2-2VOLTAGE CONVERTOR CIRCUIT. [3]

26
2.3.2 Network and Data Protocol
The data is transmitted from the user to the remote laser system through an
Ethernet connection. For this, there is a network protocol that is required. The
laser system acts like a server usually and waits for the client to connect. Each
coordinate that is transmitted to the laser system gets saved in a singly-linked
list. The x- and y-Coordinate specifies the position of the laser point on the 2D
surface to which the laser system projects the images.
Every coordinate is run 25 times per second. The coordinates are sectioned
into objects. Every object has a consecutive number. Each TCP/IP Package
has to consist of 10 bytes. As the Hardware has mechanical limits, the
coordinates must have a defined, equal distance. The distance should be
possible to adjust in the GUI. GUI and laser system have to add consecutive
IDs to the objects. The ID starts with 1.
The packets start with the operation code that defines the action to be carried
out by the laser pointer. There is a code of the X and Y axis and to the
intensity of the laser light. There are actually 5 operations performed by the
laser.
1. Add co-ordinates which adds the co-ordinates to an existing object to
form either a circle, arrow or a line (free form). This also creates a new
object when the object ID is defined as 1.
2. Move Objects, specifies the object that needs to be moved. It is mostly
used in case of using the laser pointer to point to something in specific.
3. Delete Objects, specifies that the object with consecutive ID shall be
deleted. It is important to note that, with this, it is possible to delete
the entire object not just a co-ordinate.

27
4. Clear Screen, specifies that all the objects in the screen can be deleted.
The laser is turned off.
5. Set Dot distance, the distance between each co-ordinate must be same
and that defines the brightness of the laser pointer. The closer the dot
distance is, the brighter the laser pointer becomes. However, since the
maximum number of co-ordinates of FRT 500 is limited to 500 co-
ordinates, this could also mean, only smaller objects, or limited objects
could be drawn.
Table 2.3 shows a general package. It is similar for the other operations as
well.

28
Field Name Type Description
1 OpCode Int 8 Sets the type of command based on the
input given to the GUI. For Example: Add
Co-ordinates
2 ID Int 8 Consecutive ID of the current Object.
Coordinates can only be added to the
object with the highest ID. The first object
that is transmitted has the ID “1”.
3 X-Coordinate Int 16 0x0000 means, that the laser beam is totally
moved to the left. 0xFFFF means, that the
laser beam is totally moved to the right.
Low Byte is transmitted first.
4 Y-Coordinate Int 16 0x0000 means, that the laser beam is totally
moved to the left. 0xFFFF means, that the
laser beam is totally moved to the right.
Low Byte is transmitted first.
5 Dimmer Red Int 8 Dimmer Value for the red Laser Diode.
6 Dimmer Blue Int 8 Dimmer Value for the blue Laser Diode.
7 Dimmer
Green
Int 8 Dimmer Value for the green Laser Diode.
8 Intensity Int 8 Master Intensity for all Laser Diodes.
Table 2.3 General package of Data used in FRT 500[3]
In case of delete object and clear screen and set intensity, the field from three
to 8 can be set to 0, directly as they have no significance at this stage. In case
of Move object, the fields from 5 can be set to zero. Alternatively, at 5 a 4 Byte
value of zero can be filled which would ultimately make the other fields zero.

29
Just as how network protocol is used for transmitted data through the
Ethernet connection, data protocol is used for transmitting byte arrays via
serial peripheral interface. In this case, five bytes are called one coordinate.
A co-ordinate consists of five bytes as
High-byte of
horizontal
position
Low-byte of
horizontal
position
High-byte of
vertical
position
Low-byte of
vertical
position
Brightness
Table 2.4 Data Protocol [3]
Apart from this two flag bytes are needed for the synchronization.
Start byte 1: 0x00
Start byte 2: 0xFF
The start and end bytes should be sent directly after booting. And then the co-
ordinates of the laser pointer should be sent as five bytes. Once this is done,
and the next co-ordinates can be added directly by sending just the five co-
ordinates. When the laser needs to be cleared, the start sequence should be
sent again. This can be repeated till the co-ordinates reach a count of 500.
2.3.3 Calibration
If the user input screen and the display screen for the Telepointer are not
same, as discussed in 2.3, it is important to have a method which helps the
Telepointer to point to the information at the exact location. Here, the user
interface could be any screen whereas, the laser has to be pointed at any two
dimensional surface. Every pixel on the user input screen has to be
transformed into a point which can be pointed at any 2D surface.
A mathematical dependency is drawn to make this possible. This is usually
obtained by 2D scaling and transformations using transformation matrix. But
since, this is dynamic and not static, a scaling factor is not available at the
beginning. A possible solution to this is to calculate calibration constants

30
using the points on the wall and the inbuilt function of the application. These
calibration constants can be stored for future operations so that, the laser
pointer system need not necessarily be calibrated every time. This calibration
constant is used as a scaling factor which then transforms the co-ordinates
from the screen to the co-ordinates on the wall.
The matrix for calculation of the calibration constants are obtained by solving
the linear equations below. Here xnand ynare the points on the laser display
and x’nand y’n are the points of the laser pointer, n ranges from 1 to 9
representing the 9 calibration points used.
⎝
⎜
⎜
⎜
⎜
⎜
⎜
⎛
𝑥𝑥1
2
𝑦𝑦1
2
𝑥𝑥1
2
𝑦𝑦1 𝑥𝑥1
2
𝑥𝑥1 𝑦𝑦1
2
𝑥𝑥1 𝑦𝑦1 𝑥𝑥1 𝑦𝑦1
2
𝑦𝑦1 1
𝑥𝑥2
2
𝑦𝑦2
2
𝑥𝑥2
2
𝑦𝑦2 𝑥𝑥2
2
𝑥𝑥2 𝑦𝑦2
2
2
𝑦𝑦2 1
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
. . . . . . . . .
𝑥𝑥9
2
𝑦𝑦9
2
𝑥𝑥9
2
𝑦𝑦9 𝑥𝑥9
2
𝑥𝑥9 𝑦𝑦9
2
2
𝑦𝑦9 1⎠
⎟
⎟
⎟
⎟
⎟
⎟
⎞
=
⎝
⎜
⎜
⎜
⎜
⎜
⎛
𝑥𝑥1
′
𝑥𝑥2
′
.
.
.
.
.
.
𝑥𝑥9
′
⎠
⎟
⎟
⎟
⎟
⎟
⎞
These calibration constants are used as scaling factors to transform the chosen
position.
𝑥𝑥′
= 𝑐𝑐1 ∙ 𝑥𝑥2
𝑦𝑦2
+ 𝑐𝑐2 ∙ 𝑥𝑥2
𝑦𝑦 + 𝑐𝑐3 ∙ 𝑥𝑥2
+ 𝑐𝑐4 ∙ 𝑥𝑥𝑦𝑦2
+ 𝑐𝑐5 ∙ 𝑥𝑥𝑥𝑥 + 𝑐𝑐6 ∙ 𝑥𝑥 + 𝑐𝑐7 ∙ 𝑦𝑦2
+ 𝑐𝑐8 ∙ 𝑦𝑦
+ 𝑐𝑐9
𝑦𝑦′
= 𝑐𝑐10 ∙ 𝑥𝑥2
𝑦𝑦2
+ 𝑐𝑐11 ∙ 𝑥𝑥2
𝑦𝑦 + 𝑐𝑐12 ∙ 𝑥𝑥2
+ 𝑐𝑐13 ∙ 𝑥𝑥𝑦𝑦2
+ 𝑐𝑐14 ∙ 𝑥𝑥𝑥𝑥 + 𝑐𝑐15 ∙ 𝑥𝑥 + 𝑐𝑐16 ∙ 𝑦𝑦2
+ 𝑐𝑐17 ∙ 𝑌𝑌 + 𝑐𝑐18
X and Y is the point chosen on the user display. The result is the transformed
points on the display.

31
2.3.4 CSCW in Health care
Health Care Organizations are held to an increasing scope of accountabilities
and they have the absolute necessity to provide high quality care. CSCW
research has been long interested in health care including examination of
medical records in collaborative clinical settings, collaborative technologies
and practices.[23] Although many prior CSCW research has been focused on
hospital and clinical settings, changing technologies in health care every day,
opens space to more CSCW research. Our goal is to improve the synergies
between medical informatics and CSCW. Most medical information systems
are targeted at users who needs to work collaboratively. [24]Telemedicine is
based on the technology of telecommunication and it is one of the
applications of CSCW. Computer Supported Teleconferencing Applications
have been developed in the field of CSCW and can provide effective support
for the telemedicine services. [25]

32
2.4 Tele-Medicine - An Overview
Telemedicine is the use of Information and communication technologies to
produce a better outcome in the medical care. World Health Organization,
WHO has adopted the following definition.
The delivery of health care services, where distance is a critical factor, by all health
care professionals using information and communication technologies for the
exchange of valid information for diagnosis, treatment and prevention of disease and
injuries, research and evaluation, and for the continuing education of health care
provider, all in the interests of advancing the health of individuals and their
communities [6].
The main purpose of telemedicine is to provide clinical support while
overcoming geographic barriers, connecting to users who are not at the same
location. It typically involves varies forms of communication technologies and
improves health outcomes in any way possible.
Telemedicine applications can be classified into two categories based on the
timing of the information transmitted and the kind of interaction between the
individuals. When pre-recorded date is exchanged between two or more
individuals at different times irrespective of the location, it is called
Asynchronous or 'Store and forward'.[7] For Example, the emails
communications between patients and doctors asking for the test results, the
telemedicine web applications that gets the user inputs with several questions
and typically gets back to the patient with the diagnosed results. On the
contrary, synchronous or real time telemedicine requires the presence of both
the doctors and patients at the same time irrespective of the location. For
Example, talking to a doctor over video conferencing. In both the cases, the
information can be sent through any text, audio or video media.
Majority of the telemedicine services focus on diagnosis and clinical
management, however, there are also biometric devices like equipment for
monitoring heart rate, blood pressure or glucose levels which are being
increasingly used to monitor patients from a distance. Though, there are
telemedicine applications that have proven to be low cost, which could be

33
effective in case of the low income countries with limited infra structure there
appear to be some significant barriers.
There are telemedicine application that have been deployed after the initial
funding and have proven to be of varying levels of success. However, there
projects do not last long, longevity is one of the most important problems of
the telemedicine endeavors. Another challenger is the cultural and human
differences. It has been a problem for some patients and even some health
care professionals to adopt to the new service models.[26] They are just so
used to the traditional methods that any new methods would be taken down
to trash. The differences in linguistic and cultural differences also hinder the
growth of telemedicine among the common locals in the underserved
communities. There are not many documentations on the cost effectiveness
and economic benefits of using telemedicine which makes it difficult to find
investors and to demonstrate to the policy makers. Another huge barrier is
that, there is no legal framework for telemedicine in most of the countries
which creates difficulty in delivering tele medical services in many countries
and jurisdictions and also the risk of liability. The technological challenges
need to be addressed as well, the lack of which could cause serious problems
like increase of morbidity and mortality.
So as to overcome these barriers, regulations pertaining to Telemedicine need
to be implemented worldwide. Laws and regulations governing the
functioning accordingly needs be instituted as well. Care must be taken to
ensure that the telemedicine is provided optimally and intelligently by the
services providers and the governments. The possibility to choose between
traditional and eHealth should be available to every patient.
Medicine Technology plays an important role in the future of Health Care.
The scientific and technical basis of Telemedicine is outstanding in many
areas in Germany. German medical technology manufacturers are positioned
well in the global market along with USA and Japan. The intensity of
Research and Technology in the Telemedicine industry is twice as high as the
entire Manufacturing sector which accounts to about 10%. The export rate of
Germany in medicine technology is about 66%. Of the many innovative
products, about one third of the turnover is achieved from products that are

34
lesser than 3 years old [27]. It is pretty evident from these facts that
telemedicine technology is still open for innovativeness and new products.
2.4.1 Innovations in Telemedicine Technology
Telemedicine application with a high potential is expected which should
include Telemedicine and Tele monitoring for chronic care. While on one
hand more people are suffering from chronic diseases, the skilled staff
required to assist the patients are considerably less. Technical developments
in the field of telemedicine and tele monitoring appear to be promising
approaches to take care of people from homes, for multidisciplinary cares and
for accessing patient’s information. Development of new software and tablet
apps will progress the growth of telemedicine [6].
The most mature area of telehealth is Tele-radiology [28]. There are many
devices and applications that can transfer the images of patients records such
as X-rays, CT scans and MRI from one hospital to another hospital for sharing
the studies with other doctors and physicians. There radiology centers can be
located anywhere near the location of the patients along with trained
teleradiologists, so that the specialists who are usually located at the city can
provide service 24x7 [29].
FIGURE 2-3 WORKFLOW OF TELERADIOLOGY[30]

35
The main reasons for development of Tele-radiology as a mainstream health
care where tele-medicine in all other medical fields is still developing are,
tele-radiology is already certified and has a legal framework. Another main
factor is their ability for insurance reimbursement . Tele-radiology also has
additional features which include sending the patients report electronically to
get a second opinion from the tele-radiology specialists. [31]
Apart from these, now tele-radiology also has portable X ray machines which
can be controlled by wire-less remote controls using different techniques such
as PLC [32], and other microcontrollers. [33]. Mini X ray machines are also
available to serve especially the military and remote locations.
FIGURE 2-4 TELEHEALTH MONITORING[34]
Another field that has many researches on tele-medicine is Cardiology. Tele-
monitoring devices are available in the markets which can be directly linked
to the specialty care hospitals nearby. The reports can be directly sent from

36
home either for a diagnosis or for a discussion. The care team located at the
hospitals are available 24x7.
Other wireless telemedicine implantable devices are available in the market
which can monitor the health of the patient and are linked to android or iOS
devices. There applications constantly monitor the health of the patients and
send alert messages in case of emergency.
FIGURE 2-5 WIRELESS IMPLANTABLE DEVICES [35]
From the University RWTH, Aachen, telemedicine pilot projects have been
executed in the medical field of intensive care. With the help of their tele-
intensive care center, a team of specialist tele intensive care nurses and
doctors and seniors physicians have their support continuously extended to
all the patients. A safe, high quality data transmission with zero delay is
employed where the doctors and patients get realistic display [36]. This shows
that the patients and the relatives of the patients as well as the doctors are
ready for more tele medicine advancements and the results of the research
could be used in telemedicine practices.
From all these ideas and concepts gathered, a new concept of using
Telepointer applications in discussion of telemedicine scenario using the
synchronous groupware PASSENGER was identified. The design of a the
application for this scenario and the implementation is discussed in the next
chapter.

37
3 OWN CONTRIBUTIONS FOR THE
DEVELOPMENT OF A NEW TELE-
MEDICINE APPLICATION
In this chapter we discuss the tele-medicine scenario that this project covers
and the architecture of the application. This chapter also talks about the
design decisions that were taken for this application and the reasons behind.
3.1 Overall Concept
A surgeon or a health care specialist located at a different places, far from the
location of the patient cannot help the patient in case of an emergency or
when a treatment is required. He might need to communicate to a junior
health care professional or his assistant to discuss the treatment methods or
possibilities of cure of certain diseases. Now-a-days a lot of video chat
applications or conferencing applications are available to do the same.
FIGURE 3-1 TELE-MEDICINE SCENARIO
Passenger clients are connected through passenger server, through the IP
address of the server. Data transfer is active between the clients and also

38
between the clients and server. This means, the Specialist or the expert
doctors are connected as clients and they could monitor and discuss anything
together.
The laser pointer is located at the far end, where the camera constantly
monitors and sends the video to the laser pointer server. The laser pointer and
the camera are connected to the laser pointer server, the raspberry pi. This is
connected remotely and the patient is also located at this particular location
3.1.1 System Architecture
The clients connected to the passenger server, i.e the doctors and the
specialist, should be able to operate the laser pointer located at the far end.
Also, the laser pointer should be accessed by only one client at a time. This
should naturally be the client that has the floor. To bring this into effect a
theoretical XOR gate is implement through program, which allows only one
client. Only the client who has the floor has the possibility to operate the laser
arm. This connection is based on sending TCP&IP packets either through
LAN, Local access network or WLAN, Wireless LAN.
FIGURE 3-2 SYSTEM ARCHITECTURE

39
3.1.2 Tools & Programming languages used
The server of the laser pointer can be accessed only through a linux based
operating system or by directly accessing the remote desktop of the Raspberry
pi using windows desktop. To program the server, usually python is used
directly on the server.
Remote Desktop connection can be used to login to the raspberry Pi Server
and access the files in the server, or edit or build a program. Figure 4 shows
the portal or the remote desktop where the details should be given.
Alternatively, PuTTy an open source serial console can also be used. This
supports the SSH network protocol. SSH or Secure Shell is the cryptographic
network protocol that helps in remote login especially in the Unix systems.
The port 22 is assigned for this purpose.
FIGURE 3-3 SCREEN SHOT OF REMOTE DESKTOP CONNECTION
However, the server program for FRT 500 was already written with C++ in
the visual studio compiler using a cross platform, this thesis also uses the
same. Visual GDB is a cross compiler which can be used in an integrated
development compiler and can be compiled directly via the Ethernet
connection, on the Unix system which runs the raspberry pi.

40
Since the client application should be built on the already existing Passenger,
it needs to be built using Delphi. Since Delphi does not have any support for
raspberry pi, data are directly sent as TCP/IP packs. The possibilities were
developing an intermediate c# application and importing this as a dll library
which is mostly done for using Delphi. The problem was because the
Microsoft version of .NET is available for free, so the programmers are
focused on that and indirectly mostly of the products support only the
Microsoft application like visual C++ or C#.NET
Alternatively, this code can be exported into the higher version of Delphi
which is currently operated by Embarcadero. Embarcadero also has an
application of C# and C++ which can be directly imported and also has the
most recent updates which Delphi provides. There is also Lazarus an open
cross platform IDE. However, the project that was developed earlier could not
be completely exported into Lazarus, as it only has a certain amount of
compatibility. On that basis, this was completely eliminated from the
comparative study.
FIGURE 3-4SSH CONSOLE OF PUTTY

41
Methods
Factors
Calling C++ dll
Calling Directly
from Delphi
Using
Embarcadero
Compiler
C++ code can be
written and
compiled using any
compiler
nil
C++ should also
be built on c++
builder
(embarcadero),
Delphi 7 should
also be migrated
to Delphi XE RAD
Studio
Compatibility
C++ should also be
compiled using 32
bit compiler
nil No problem
Libraries
.dll library needs to
be created and that
should include
practically all the
classes
There is no
automatic
conversion tool
that seem to work
fine. It has to be
done manually.
No need to
include any
libraries. The
functions can be
called directly
from the different
units.
Reliability
Once these libraries
are generated and
executed there is no
problem
Even if the c++
code at the client
side of the
FRT500 is
converted into
delphi it still
needs to
communicate
with the c++
program in the
raspberry PI
There will be
problems during
the runtime
because of the
Unicode. Delphi
XE is stricter than
delphi 7 meaning
the low level
string handling
needs to be taken
care of.

42
Methods
Factors
Calling C++ dll
Calling Directly
from Delphi
Using
Embarcadero
Adaptability
Any later changes in
either the c++ code
or the delphi code
would not affect the
project
Any changes in
C++ code should
also be manually
reflected in the
delphi code.
No problem
Flexibility
This way any other
c++ code can also be
linked in the future
It is not possible
The c++ codes
should first be
built on the c++
builder and only
then can be
converted
Table 3.1 Comparative study of different methods of interfacing

43
3.2 Graphical User Interface
The GUI must provide usability to the clients by enhancing the efficiency and
ease of use [37]. It should also be interactive and complete so that the desired
activities could be performed.
For this application, where the users are medical doctors and specialists. They
might not have many ideas about computing. So the user interface needs to
simple and easy to use. Since it is an application dealing with health care, the
life and health of patients are at stake. This was considered and the user
interface was created with different panels giving no chance to confusion and
mistakes.
Considerations:
• Participants must be able to view and manipulate a common set of
objects.
For Example: For a Diagnosis or planning all the physicians must be
able to view the images.
• Users must be able to share their thoughts at any point of time.
Considering the case with the Expert surgeons at the near end and Co-
surgeons with less expertise at the far-end with the patient, the expert
surgeon must be able to provide his opinion anytime, even during the
hours of surgery or discussions.
Figure 3-5 shows the overall design of this shared workspace.

44
3.2.1 Components & Function
Editor Panel:
Editor Panel includes the tools of the shared workspace. The new unit
FRTEditorPanel.pas includes the design and operation and
TelemedicineToolForm.dfm and TelemedicineToolForm.pas has the form.
FIGURE 3-5OVERALL DESIGN OF THE SHARED WORKSPACE
However, like in the CASE tools, the form directs to the .pas unit and the
design and operation are carried out at the application level from there.
Editor Panel has three panels. Annotation Panel, Robot-arm Panel and
Functions Panel. Figure 3.6 Shows the Screen Shot of the Editor Panel.
Annotation Panel:
Annotation provides a natural way for people to interact with multimedia
content. Annotations are graphical object specifying a region of interest in the
annotated image. [38] This provides one or more details. The graphical objects
could be anything. It makes more sense to have these rounded up to three: A
circle, an arrow and a freeform. A details panel contains these 3 objects.
Consider 3 users diagnosing a patient’s oral health, the patient or the patient’s
image and the robot arm are assumed to be with the same user, User A., other
2 users are User B and User C.

45
FIGURE 3-6EDITOR PANEL
To diagnose and discuss the treatment methods, User uses Circle to
emphasise on the location of the ailment 3.7. However, under certain
circumstances a precise depiction of the ailment may be required. That is
when the user users free form, Figure 3.8 while at times just pointing out to
the ailment may be enough. Figure 3.9.
However, annotations make more sense when they are accompanied by a
short text. Notation refers to the short text that refers to the detail that is
outlines. For ex. In Figure 3.7 . This text is only for the reference of the other
users, not for the robot arm display.
Since Medicine is a more complicated topic than Engineering, having a
Notation, a text, helps the users in an effective communication.
Most-likely situations:
• When the chair holder is not audible.
• When the topic of discussion is complex.
• When the topic of discussion is ambiguous or unknown to the other
users.

46
FIGURE 3-7 EDITOR PANEL: CIRCLE, NOTATION
The Notation has a limitation of 50 letters, this is obviously required as this
should not hinder the visibility of the image to other users.
There are also situations when a short explanation about something is
required. Overlays, [39] multiple texts grouped together to give more details
about the annotated image can be used.
However, such a long text could probably hinder the image and the users
have the possibility to view or cancel this text at any time during the session.
There is no word limitation. The text box is of a standard size and can be
scrolled down for longer texts. 3.8
When is it sensible to use Overlay?
• When the process involves risk of human life
• When the process has a higher probability of mistakes.
• When the chair holder has a higher level or expertise compared to
others.
Property displays the information about the author (Chair Holder) and the
time stamp.
The major difference between group learning, group work related to
engineering and medicine is that, with medicine, every step needs to be more
careful and archived. With the former, a mistake could cost billions, but with
Cavity - Decoloured

47
the later, it could cost agony and human life. So, at every level of discussion, it
needs to archived, for later reference.
FIGURE 3-8 EDITOR PANEL FREE FORM, OVERLAY
Robot-Arm Panel:
Robot-Arm Panel includes the communication with the telemedicine laser
tool.
This includes options to transmit, Capture a picture, laser pointer and to stop
the laser.
FIGURE 3-9EDITOR POINTER: ARROW
Xylitol is a
naturally
occurring sugar
substitute that
has been shown
to reduce the
level of mutants
streptococci in
plaque and
saliva and to
reduce tooth
decay. It has
been

48
Stop Laser:
There could be reasons when the laser needs to stop displaying. For Example,
once the Floor holder has finished explained, or when he thinks he made a
mistake or when he wants to change his details.
Laser Pointer:
There is also a possibility of using a laser pointer. This acts exactly like a
presentation laser. The functionality is similar to that of a Telepointer. The
mouse cursor of the Right holder can be used to point to certain location or a
point to emphasize its importance.
3.2.2 Picture/ Video Capture
Another important design decision is to choose the camera suited for the
application. The functionalities of the camera as discussed below were
considered before choosing the camera.
Picture Capture:
The real time picture of the artefact/Image is captured. Once the user chooses
this option, the current picture is replaced by the new picture.
Case1: When the user is working on the Details and has not transmitted them
yet.
In this case, the user gets a message, “Are you sure? Your data will be
destroyed”. If the user chooses to capture a new picture, the old picture will
be replaced by the new picture.
Case 2: When the user has transmitted the Details.
The picture including the current laser display is captured and this replaces
the old picture.
Advantages:
• To identity if the laser is pointing at the same location the user means.

49
• When the image/artefact is not constant, when it is moving or rotating.
• To get the higher resolution real time image.
3.2.2.1 Camera
Camera can be implemented by connecting it to the server of the laser pointer,
which means it has to be directly connected to raspberry PI. There is a
possibility to use either a webcam connected via USB or the raspberry Pi
camera module.
Using a webcam connected directly to the USB gives numerous possibilities of
different camera. Considering a scenario where the specialist and juniors
discuss the health of a patient or details or a possible surgery, the quality of
the video and the speed of the camera are the most important factors. Only
few webcams are available in the market for this purpose. One such available
webcam is Logitech C920. This is a 1080p high definition camera which is
faster than most web cameras available in the market. It has good frame
quality, auto light correction, autofocus and ease of use.
However, this gives only limited usage in terms of functionality when used
along with the raspberry pi as the usb cameras need to be separately
programmed. There is a camera module that matches raspberry PI. This can
be used for quick operations and can easily be interfaced with Delphi while
USB camera needs an extra .dll for such an operation.
Raspberry pi camera module also give high Definition videos and still
pictures. The serial cable of the Raspberry pi camera module is attached to the
slot for camera (CSI port) provided in the raspberry pi. Once this is connected
the camera software should be enabled. [40]

50
FIGURE 3-10 RASPBERRY PI CAMERA MODULE
To enable the camera the following code should be given in LT Terminal of
the raspberry PI.
sudo raspi-config
Enable Camera
Finish
The camera would be activated.
The control of the camera can be done directly from the application, however,
the camera server must be turned on before starting. Once the video is
streamed from the server, it can be viewed from any VLC player. In this
thesis, it is done using the VLC (Video LAN Client) module which is available
for Delphi.
For starting the video streaming at the server, the following code must be
entered either in the LT terminal or the raspberry Pi remote desktop or at the
SSH portal in PuTTY. [41]
sudo apt-get install vlc

51
This installs VLC at the raspberry Pi server.
Raspivid –o - -t 0 –n | cvlc –vvv stream:///dev/stdin –sout
‘#rtp{sdp=rtsp://:8554/}” :demux=h264
This streams the video using RTSP.
However, this project requires the camera take Pictures and Video, which are
two different tasks, that cannot be performed by a single camera with the
current version of Raspberry Pi. Hence both the cameras are used, the
raspberry Pi camera module to take a still picture and the USB camera to take
the video.
FIGURE 3-11 LOGITECH C290 USB WEBCAM

52
3.3 Floor control & Communication Windows
Effective collaboration is the cornerstone of a groupware application.
Different levels of communication between the participants is required to
improve user feedback in highly interactive user interfaces. Floor handling is
established in Passenger to control the synchronous sessions and a control
system to handle different permissions.
Groupware also requires the information to be shared equally among all the
participants. In Passenger, a relaxed form of What You See Is What I See,
WYSIWIS is implemented, where every member has the same view in the
Public window and a separate working space in the Private window.
Telepointer, a special cursor is used to point the information shared in the
screen of Public Window.
Passenger has Passenger Floor Control Model as a co-operation tool which is
designed at the server level. Common workspace and audio transmission
channel are administered by Floor Control. However, with Passenger as a
Tele-medicine application, this thesis does not require Floor control for most
parts. So we have an option to choose between the Floor Control mode and
Moderator mode.
In Moderator mode, floor is not passed between all the clients. The client at
the far-end with the laser arm is excluded from the Floor-list and the other
clients co-author the laser arm activities. This means, Floor is always with the
client at Far end by default and he is the Moderator. However, once the Floor
is passed, the Floor-Holder can hold the floor as long as they want. But the
floor can only be returned to the Far-end client. The others have an option of
intermediate call, this intermediate call does not pass the Floor, but allows the
Holder be heard.

53
3.3.2 Communication Components
An important design decision concerning the communication component is
that the position and size of the windows should not be changed. Local client
has the Top-Left window and Tele-Medicine video captured at the far end is
displayed at the Top-Right. On clicking Picture capture from the Tele-
Medicine tools, the current image would be captured and displayed on the
work space in high resolution.
However, the videos of the clients and the screen can only be restricted to
limited resolution, another important decision is the maximum number of
clients. For the feasibility and comfort of this thesis, the maximum number of
clients is considered to be 3. The video can also be optionally viewed in the
public window.
FIGURE 3-12 PASSENGER COMMUNICATION COMPONENTS

54
3.3.3 Moderator Based Floor Control
Moderator based Floor control is a method where the floor can be assigned to
other users directly by the moderator.
When a group of participants are logged into a groupware with moderator
based floor control, if the floor is available, it is assigned to the user from the
list of requested users. If the floor is not available it is queued into the floor
list. The request could also be denied.
FIGURE 3-13 MODERATOR BASED FLOOR CONTROL SCENARIO
What is implemented in this system is a modified moderator based control
where the moderator is not fixed. The current floor holder becomes the
moderator. Which means when the floor needs to be released the moderator

55
who is also the current floor holder, chooses which of the other users in the
floor list gets the floor next.
Theoretical XOR GATE:
In section 3.1 we talked about a theoretical XOR gate. The theoretical XOR
gate is implemented by programming it in Delphi in the component called
PermissionPanel.pas
The major purpose of this theoretical XOR gate is to limit access of the laser
pointer system to the Floor holder. It simply does not make any sense to let
everyone access it. So only the floor hold can access it.

56
3.4 Control of FRT-500
FRT 500 needs to be controlled from Passenger effectively to establish this
interface. To control FRT 500 from passenger, a new tool has to be designed
and added into the passenger, the functionalities of which were explained in
chapter 3.2.1. This new tool is programmed in Delphi 7 along with Passenger.
A new component called FRTEditor.pas is developed which is included in the
package. This component is accessed using the form TelemedicineEditor.pas,
which is called directly from the source code.
The components are not statically added to the .dfm form, however, it is
added dynamically in FRTEditor.pas considering the safety of the application.
Different panels are created for buttons and the functions are assigned to
these by using switch cases and nested if.
The functionalities for controlling the laser can also be created dynamically.
The TCP/IP packets can be sent directly to the laser pointer server. The
following snippet shows the function which sends the information packet to
the server.
Function TMeinEditorBase.addCoordinates(point: TPoint ; objId : integer) :
TByteArray;
var
a,b : array[0..3] of byte;
begin
setLength(Result,10);
move(point.X, a[0], 4 );
move(point.y, b[0], 4 );
Result[0] := 1;
Result[1] := objID;
Result[2] := a[0];
Result[3] := a[1];
Result[4] := b[0];
Result[5] := b[1];
Result[6] := 0;

57
Result[7] := 0;
Result[8] := 0;
Result[9] := 120;
end;
The pros and cons of the programming languages need to be considered as
well while creating a tool like this. In Delphi the values cannot be converted
directly into bytes and so it has to be moved manually. Also, the because of
the possibility to assign values directly into the array elements, this is feasible.
The major part of this interfacing would be to establish a connection between
passenger and the laser pointer. The connection can be established both
directly and dynamically. Here I have established the connection directly,
however, it is executed dynamically. The below code is the procedure which
creates a memory stream dynamically and connects to the laser pointer at this
IP address 192.168.0.2
stream := TMemoryStream.Create;
stream.Write(buf[0], length(buf));
stream.Position := 0;
TcpClient1.RemoteHost:= '192.168.0.2';
TcpClient1.RemotePort := '1234';
Tcpclient1.Active := true;
TcpClient1.sendstream(Stream);
Thus the FRT 500 can be controlled from the telemedicine application of the
synchronous groupware PASSENGER. All the design decisions that were
discussed in this chapter were implemented in the application and the next
chapter discusses the first evaluations of this application in the labs of
University of Duisburg Essen.

58
4 FIRST EVALUATIONS
In this chapter the results of the test run of the application are discussed. The
testing was done at lab with PASSENGER server setup locally. The main goal
was to find out if this system could be used effectively as a telemedicine
application based on the ease of use and to find out if the interfacing between
the laser pointer and PASSENGER could be stable.
4.1 User Interface
The user interface was tested to determine the usability and competence of
the application. Testing uncovers how easy or difficult it is to use the
application and to figure out the unidentified problems so far, so that
solutions can be found.
A heuristic evaluation of the application was done at the Department of
Computer Engineering, University of Duisburg Essen. Testing was done by
different groups where one group was students who were not very different
from the possible users and were not aware of the application and other
group which was very similar to the user group and aware of the
applications.
Before the evaluations a questionnaire was given to all the participants to get
a picture of their comfort levels with a tele-medicine application and
groupware processes (Appendix).
Potential users of this application need not necessarily be people who are
aware of groupware and group-processes as they would be medical doctors
and health care assistants. However, it is also not limited to a group of just
medical doctors. So a diverse group of participants was selected to do the
testing.
The participants were given specific tasks during the study so that maximum
errors could be found. The tasks were divided into two parts. One part was
dedicated for the Telemedicine tools and the next part was for the evaluation
of communication components. The main objective of this testing was to test

59
the User interface , to use all the components of the Telemedicine tool, to use
the calibration option to calibrate the laser pointer and Floor Control options.
After the completion of test another questionnaire was given to all
participants to obtain the information on the usability and user satisfaction
(Appendix). The results from this survey show that this application can be
used as a telemedicine application provided the users are aware of some basic
groupware concepts like floor control, shared context.
The above graph shows the users rating for both the telemedicine tool and
Floor control and communication components. Also, the overall rating was
provided by the users, which suggests the overall rating of this application is
good.
3.8
3.9
4
4.1
4.2
4.3
4.4
4.5
4.6
User group 1 User group 2
Study of User Interface
Telemedicine Tool Floor Control Overall rating

60
FIGURE 4-1 SCREENSHOT OF VIDEO CAPTURE IN THE TELEMEDICINE
APPLICATION
FIGURE 4-2SCREENSHOT OF THE TELEMEDICINE TOOL

61
4.2 Laser projections on 2D surface
The Laser projection on the 2D surface projected by the client application has
been well calibrated and does not normally have any problems. Different
shapes and laser pointer are executed well and works fine.
However, the problem arises only when the number of co-ordinates reach
above the limit, 500 co-ordinates. Above this limit, the laser projection is
distorted and becomes shaky.
What is needed is an information on how many co-ordinates are being used at
every point of time. Lack of this information creates a possibility of using up
all the co-ordinates leaving the system unstable.
FIGURE 4-3 CALIBRATION SCREEN IN PASSENGER
Another easier solution for this is to set up the dot distance high. By setting
up higher dot distance, the brightness of the projections is reduced, but more
objects can be drawn before the system becomes instable.

62
FIGURE 4-4 CALIBRATED LASER POINTER.
Co-ordination between the laser projections and the passenger system
established using calibration is well established and works well.

63
4.3 Test Results
The test run of the application suggests that there are no major problems with
most of the application. However, the problems mostly lie with the quality of
video. This could be because of the delays that is cause during the
transmission and the buffering of video.
The reasons for this delay in transmission of videos is because of the server
that is being used at the laser pointer, the raspberry pi. Raspberry pi is often
not responsive enough to support high quality video transmission. In most of
the cases, raspberry pi camera is used as a surveillance camera, which does
not need higher resolution.
Fortunately, this problem is not un-resolvable, but it needs additional
components. The first and simple step is the use of a faster MicroSD card
which could have a faster read/write and processing speed. However, this
could alone not solve the problem. Currently, raspbian is the operating
system. But several other open source operating systems are available for
raspberry Pi which are light and can run high resolution videos.
Even if all of these are done, the quality of videos with current version of
raspberry pi can’t be exactly high quality because of the hard limitations of
raspberry pi. With dedicated camera and application this can be achieved, but
it is important to remember, raspberry pi is already running another
application.
Another problem is the limitation of using 500 co-ordinates with FRT 500. As
the number of co-ordinates is limited, the number of objects that can be drawn
using the laser pointer is also limited. After reaching the 500 co-ordinates, the
laser pointer starts to distort producing projections that are not accurate.
However, as it is going to be used in an application where larger projections
are not required, this would not be a huge problem.
Even though raspberry pi is the current trend, there are many other boards
which are faster and provide more power. The version of raspberry Pi on the

64
Laser Pointer system is already the older version when compared to the
newer versions available in the raspberry Pi market. Furthermore, boards like
beaglebone, banana Pi and Arduino provide more power and support. [42]
The laser pointer was calibrated mathematically at the client side. To calibrate
this the client should be connected to the laser pointer and should see the
laser pointer and the 2D surface. Alternatively, calibration can be done
automatically by the system by identifying the video coverage. It means, the
laser pointer will be calibrated based on the video screen.
FIGURE 4-5. GUI OF FAR END SITE
Figure 4.6 shows the picture of the telemedicine application of the
synchronous groupware PASSENGER who is located at the far end. The
public window of the participant displays the video of the laser pointer
projection located at the Near end with the laser pointer. The user can choose
to see the video at any point during the session.
Figure 4.7 gives an image of the near end. The camera connected to the laser
pointer FRT500 constantly monitors the projections and sends the video to all
the participants logged into the current session.
FIGURE 4-7 NEAR END WITH THE LASER

65
Figure 4.8 shows the results of the movements in the tele-pointer tool that can
be observed in the near end from movement of the laser application. A
feedback is sent to the far-end client in the form of video communication.
FIGURE 4-8 LASER POINTER AND THE USER LOCATED AT THE NEAR END
FIGURE 4-9 (LEFT) USER AT THE FAR END SITE USES THE TELE-POINTER APPLICATION OF
PASSENGER TO CONTROL THE FRT500 . (RIGHT) OUTPUT OF FRT500

66
5 CONCLUSION AND OUTLOOK
Groupware systems and tele-pointers can be operated together and can create
a major difference in the field of telemedicine. This thesis has evaluated and
designed the possibility of PASSENGER, the synchronous groupware to be
used as a tele-medical application. An architecture was designed and a user
interface was developed as a first step. The interface between the Telepointer
and the groupware system was established by sending TCP/IP packages.
Experimental evaluations had been conducted at every stage and a survey
with two different group of users have also been taken at the end. The results
clearly indicate that this application can be used as a tele-medicine
application.
This Tele-medicine Passenger Application can find its use in improving the
health care solutions provided to any remote users. It can be used in the
Military facilities and space centers. It can also be used in war affected areas
and refugee locations where there could be a possible lack of health care
professionals.
As telemedicine applications are slowly evolving, there is a strong
requirement for such an application in the future. By additionally including
data transferring and bio signal capturing, this tool can be used additionally
for tele-diagnosis and tele-medical-discussions in the field of Cardiology. [43]
Portable X ray machines are the current research interest in the field of
Radiology. There portable X-Ray machines have the possibility to be
controlled by a wireless remote control. Currently, wire-less remote control
for these devices are built using PLC[32]. Passenger Tele-medicine application
can be further developed to support devices like this where the shared
workspace can be used to view the results immediately. If, Laser pointers can
also be included in these synchronous groupware systems, then a 'Tele-
Diagnosis and Discussion Application' in the field of Radiology would be
possible.
Treatments and Discussions in the field of ENT can be provided by
telemedicine. This usually uses camera and video conferencing applications

67
with the patients and Doctors. The passenger Telemedicine application has
the scope to provide solutions that could make tele-medicine better in the
field of ENT as well. [44,45]

68
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