6

IEEE TRANSACTIONS ON INFORMATION TECHNOLOGY IN BIOMEDICINE, VOL. 16, NO. 1, JANUARY 2012

A Reliable Transmission Protocol for ZigBee-Based

Wireless Patient Monitoring
Shyr-Kuen Chen, Tsair Kao, Chia-Tai Chan, Chih-Ning Huang, Chih-Yen Chiang, Chin-Yu Lai,
Tse-Hua Tung, and Pi-Chung Wang

AbstractPatient monitoring systems are gaining their importance as the fast-growing global elderly population increases demands for caretaking. These systems use wireless technologies to
transmit vital signs for medical evaluation. In a multihop ZigBee
network, the existing systems usually use broadcast or multicast
schemes to increase the reliability of signals transmission; however,
both the schemes lead to significantly higher network traffic and
end-to-end transmission delay. In this paper, we present a reliable
transmission protocol based on anycast routing for wireless patient monitoring. Our scheme automatically selects the closest data
receiver in an anycast group as a destination to reduce the transmission latency as well as the control overhead. The new protocol
also shortens the latency of path recovery by initiating route recovery from the intermediate routers of the original path. On the basis
of a reliable transmission scheme, we implement a ZigBee device
for fall monitoring, which integrates fall detection, indoor positioning, and ECG monitoring. When the triaxial accelerometer of the
device detects a fall, the current position of the patient is transmitted to an emergency center through a ZigBee network. In order
to clarify the situation of the fallen patient, 4-s ECG signals are
also transmitted. Our transmission scheme ensures the successful
transmission of these critical messages. The experimental results
show that our scheme is fast and reliable. We also demonstrate that
our devices can seamlessly integrate with the next generation technology of wireless wide area network, worldwide interoperability
for microwave access, to achieve real-time patient monitoring.
Index TermsAnycast, broadcast, ECG, multicast, patient
monitoring, vital sign sensor, worldwide interoperability for microwave access (WiMAX), ZigBee.

Manuscript received October 1, 2010; revised April 19, 2011; accepted

October 1, 2011. Date of publication October 13, 2011; date of current version February 3, 2012. This work is supported in part by the National Science
Council under Grant NSC98-2218-E-241-004 and Grant NSC99-2221-E-005015.
S.-K. Chen was with the Department of Computer Science and Engineering, National Chung Hsing University, Taichung 402, Taiwan. He is now with
Aerospace Industrial Development Co., Ltd., Taichung 40760, Taiwan.
T. Kao is with the Department of Biomedical Engineering, Hungkuang University, Taichung 43302, Taiwan.
C.-T. Chan, C.-N. Huang, C.-Y. Chiang, and T.-H. Tung are with the Department of Biomedical Engineering, National Yang-Ming University, Taipei
11221, Taiwan.
C.-Y. Lai was with the Department of Computer Science and Engineering,
National Chung Hsing University, Taichung 40227, Taiwan. He is now with
Gemtek Technology Co., Ltd., Hsinchu 30352, Taiwan.
P.-C. Wang is with the Department of Computer Science and Engineering, National Chung Hsing University, Taichung 40227, Taiwan (corresponding author,
e-mail: pcwang@cs.nchu.edu.tw).
Color versions of one or more of the figures in this paper are available online
at http://ieeexplore.ieee.org.
Digital Object Identifier 10.1109/TITB.2011.2171704

I. INTRODUCTION
CCORDING to Kinsella and Hes [1] report from the
US Census Bureau, the global elderly population is fast
growing and will outnumber the population of children in near
future. The aging society is bringing its impact on many developing countries and presents a stark contrast with the low
fertility rate of these countries. The changes brought about by
the aging society include an increasing demand for caretaking;
thus, patient monitoring systems are gaining their importance
in reducing the need for human resources. Caretaking homes
and hospitals have been planning on the use of biological sensors to effectively minister to their patients. Vital signs, such
as body temperature, blood pressure, and sugar level, can be
regularly collected and remotely monitored by medical professionals, achieving a comprehensive caretaking system.
The transmission of vital signs in nursing homes and hospitals is usually carried out wirelessly. The vital signs can be
categorized into emergency messages and regularly collected
information. While the regularly collected information can be
stored and transmitted in a given time period, the emergency
messages must be transmitted immediately. The transmission
path of vital signs can be divided into outdoor and indoor. The
technology of wireless wide area networks (WWANs) is used
for outdoor transmission, and that of wireless mesh network
(WMN) is responsible for indoor transmission.
Long term evolution (LTE) and worldwide interoperability for
microwave access (WiMAX) are the next generation technologies for WWAN. Both technologies aim at providing wireless
broadband access service and have the same core wireless technologies, but in different manner. While the technology of LTE
considers incumbent deployments, which pursue compatibility
with the existing devices, WiMAX is primarily used in fixed to
mobile deployments. These technologies will greatly improve
the quality of patient monitoring since the vital signs can be
transmitted with better bandwidth management.
For the indoor transmission of vital signs, WMN is a convenient technology, which can dynamically establish a multihop
network topology without prior configuration. The WMN devices could change locations and configure itself on the fly. They
are also widely adopted for indoor positioning [2][5]. These
devices have advantages of power efficiency, low cost, and small
volume and size. ZigBee [6] is an open standard technology to
address the demands of low-cost, low-power WMNs via shortrange radio. ZigBee is targeted at RF applications that require a
low data rate, long battery life, and secure networking. Its mesh
networking also provides high reliability and more extensive
range. The ZigBee devices can be combined with WWANs to

1089-7771/$26.00 2011 IEEE

CHEN et al.: A RELIABLE TRANSMISSION PROTOCOL FOR ZIGBEE-BASED WIRELESS PATIENT MONITORING

achieve a seamless platform of wireless patient monitoring. Yet,

the current standards of ZigBee do not consider the reliability
of transmitted messages in a multihop network topology. ZigBee may not be suitable for transmitting vital signs, especially
for emergency messages, since these messages are critical for
diagnosing the illness of patients as well as providing important
clues to the urgency level.
In this paper, we present a reliable protocol of packet forwarding that transmits emergency messages with vital signs on
a multihop ZigBee network. We deploy multiple data sinks in
a ZigBee network. Our protocol uses anycast to find the nearest available data sink. When the path to the original data sink
fails, our protocol automatically selects another data sink as
the destination. The transmission path is rebuilt from the last
node before the failure link; hence, the latency of path recovery is shorter than that for the unicast-based approaches that
must rebuild a path from source node. As compared with multicast/broadcast approaches, our protocol significantly reduces
the traffic overhead while maintaining the reliability at the same
level. With our reliable transmission protocol, we implement a
ZigBee device for fall monitoring, which integrates fall detection, indoor positioning, and ECG monitoring. When the triaxial
accelerometer of our device detects a fall, the current position of
the patient is generated and transmitted to a data sink through a
ZigBee network. In order to clarify the situation of the fallen patient, 4-s ECG signals are transmitted along with the emergency
message. The new protocol ensures that these critical messages
can be transmitted successfully. In our simulations, we consider
the traffic overhead, the latencies of the transmitted messages,
and path recovery. We also show the prototypes of our ZigBee devices and demonstrate the feasibility of our scheme by
integrating our protocol with WiMAX.
Our paper is organized as follows. Section II provides a
brief discussion of previous work on mobile healthcare systems.
Section III describes the reliable transmission protocol, followed
by the fall monitoring system in Section IV. The simulation results and the implemented prototypes are shown in Section V.
Section VI presents our conclusions.
II. RELATED WORK
A. Communication Modes
Data transmission can be categorized into four modes,
namely, unicast, multicast, broadcast, and anycast. Both multicast and broadcast are one-to-many transmission, but multicast
communication must specify the address of the multicast group
to identify the potential receivers. Since multicast and broadcast
can deliver messages to multiple receivers, they are suitable for
the applications demanding stringent data integrity. Nevertheless, their weakness stems from the large number of packets that
may impede the transmission rate. Unicast differs from previous
two modes in that it delivers packets only to a single receiver.
Unicast transmission has the least traffic overhead; however,
when the path to the receiver fails, additional procedure of path
recovery must be carried out to find another receiver.
Anycast is a new network routing approach in which messages from a sender are routed to the topologically nearest re-

TABLE I
TRANSMISSION MODES

ceiver in a group of potential receivers. The group is called an

anycast group, and the receivers in the same anycast group are
identified by the same anycast address. Anycast can be treated
as a subclass of multicast that finds the nearest receiver. As
compared with the previous communication modes, anycast has
lower traffic overhead than broadcast and multicast. Anycast
also has better reliability than unicast since it is capable of selecting a new receiver. However, anycast routing increases the
complexity of the network devices. The path recovery latency of
anycast is also longer than that of multicast/broadcast. A better
balance between the implementation complexity and the path
recovery efficiency is thus critical to the successful deployment
of an anycast-based protocol. We list the properties of these
transmission modes in Table I.
Anycast has been used in the following applications.
1) The nearest or best server selection [7][9]: A client can
communicate with the nearest server with an anycast address. This application can be used to support emergency
calls (e.g., call for an ambulance).
2) Service identification [10], [11]: Anycast addresses can
be used to identify unique services, such as domain name
system and HTTP proxy in the Internet.
3) Improving system reliability [12]: We can assign an anycast address to multiple servers scattered. If one of the
servers fails, packets will be routed to another nearest
server without interrupting service.
4) Policy routing [13]: Assume that an anycast address is
assigned to the network interfaces of a group of routers. By
specifying the anycast address in the hop-by-hop routing
option, packets are forced to transmit via one of the routers
in the group.
Developing an efficient anycast routing protocol for ad hoc
wireless networks is a challenging task [14]. Although many
anycast protocols have been deployed in wired networks, these
protocols cannot be applied to wireless networks since every
node can move arbitrarily. An anycast approach can use message broadcasting to transmit service request messages [15].
The sender then selects the best receiver from the received response messages. Such approach usually produces high traffic
overhead. Also, when the number of nodes increases in a wireless network, the possibility of packet collisions increases and
the packet delivery ratio decreases [16].
B. Wireless Patient Monitoring Systems
Currently, a number of studies have been proposed to address the issues of transmitting vital signs in nursing homes and
hospitals over wireless transmission. We briefly overview some
research of mobile patient monitoring systems.

IEEE TRANSACTIONS ON INFORMATION TECHNOLOGY IN BIOMEDICINE, VOL. 16, NO. 1, JANUARY 2012

Varshney [17] proposed a framework of patient monitoring

systems, including patient monitoring devices, ad hoc wireless
networks, and the receivers for healthcare professionals. This
framework uses four routing schemes (multicast, reliable multicast, broadcast, and reliable broadcast) and several enhancing
schemes to improve the transmission reliability over wireless
ad hoc networks. The characteristics of the framework are summarized as follows: 1) transmission with increased power for
finding a healthcare professional; 2) multiple retransmissions
and hop-by-hop acknowledgments; 3) increased number of cooperating devices, fixed devices, or healthcare professionals;
4) transmitting differential values of vital signs; and 5) use of
multiple wireless ad hoc networks.
Jovanov et al. [18] present wireless distributed data acquisition system. The system uses personal digital assistant as a mobile client to acquire data from individual monitors and synchronizes collected records with existing records on the telemedical
server. Each client device uses local flash memory as a temporary storage until reliable connection with a mobile client is
established.
Istepanian and Petrosian [19] present an optimal zonal
wavelet-based ECG data compression method, which reaches
a maximum compression ratio of 18:1 with low-percent rms
difference (PRD) ratios for a mobile telecardiology model. The
method also attains an ambulatory speed of up to 100 km/h in
urban channel profiles with a bit error rate of less than 1015
and with an average reduction of 73% in the transmission time.
Varshney and Sneha [20] proposed protocols for power management under varying user densities, power levels, and numbers of hops to support a diversity of devices. Their scheme
provides a reliable message delivery at reasonable transmitted
power.
Cypher et al. [21] surveyed previous work on wireless communications in support of healthcare networks. The authors only
consider the case of one-hop transmission. From an analytical
perspective, while using IEEE 802.15.4 standard for ECG, the
maximum payload size only allows up to 118 samples per frame
bringing the accumulation delay to 236 ms. The minimum data
sampling rate of 1 sample per frame results in an accumulated
delay of 2 ms.
Overall, we notice that the previous schemes tend to use
broadcast or multicast schemes to achieve reliable message delivery in a multihop wireless network. However, the cost of
network traffic is also significantly increased. Although the
number of transmission hops and traffic overhead can be reduced by using excess transmission power, the collision domain
is also enlarged to severely degrade the transmission efficiency
of MAC layer. Therefore, we combine anycast with a reliable
transmission mechanism to improve the efficiency of message
transmission in this paper. Since our scheme does not rely on increasing transmission power, the power efficiency of our scheme
can be improved as well.
III. RELIABLE TRANSMISSION PROTOCOL
In our network architecture, we categorize the nodes into
three types: sensor, router, and data receiver. The sensor node

Fig. 1.

Architecture of our wireless patient monitoring system.

acquires vital signs and encapsulates these data in packets. Then,

the sensor node transmits packets to a data receiver through the
closest router. We assume that the sensor node is mobile. Thus,
the path to the data receiver would consistently change. Router
node is responsible for forwarding messages to a data receiver.
Since we use an anycast routing protocol, the data receiver is
the nearest one. The data receiver node acts as a data sink,
which collects physiological information and transmits to the
medical or emergency center. As mentioned previously, the data
receiver node can be combined with WWAN technologies, such
as LTE or WiMAX, to achieve a seamless platform of wireless
patient monitoring. We depict the architecture of our platform in
Fig. 1. In our platform, the router nodes form a multihop WMN.
To ensure successful transmission in the WMN, we propose a
reliable transmission protocol based on the ad hoc On-Demand
Distance Vector (AODV) routing protocol [22].
Before introducing our protocol, we briefly describe the design merit of AODV. The AODV routing protocol is an ondemand algorithm, which builds routes to the destination only
as desired by source nodes. There are two types of packets, route
request (RREQ) and route reply (RREP), used in the route establishment. When a source node attempts to communicate with
a destination whose route is unknown, it broadcasts an RREQ
packet across the network. The RREQ contains the address of
the source node, current sequence number, broadcast identifier,
and the most recent sequence number for the destination of
which the source node is aware. Nodes receiving an RREQ update their information for the source node and set up backward
pointers to the source node in their routing tables. A node receiving an RREQ sends an RREP if it either is the destination
or has a route to the destination. The RREP is sent to the source
by using unicast. Otherwise, the router node rebroadcasts the
RREQ to its neighbors. Each node keeps track of the RREQs
source address and broadcast identifier. If a node receives an
RREQ which it has already processed, it simply ignores the
RREQ. As the RREP propagates back to the source, nodes receiving the RREP set up forward pointers to the destination in
their routing tables. Once the source node receives the RREP,

CHEN et al.: A RELIABLE TRANSMISSION PROTOCOL FOR ZIGBEE-BASED WIRELESS PATIENT MONITORING

Fig. 2.

DATA message format in the 802.15.4 MAC data payload.

it begins to forward data packets to the destination. Each node

could update its routing information for a destination if it receives an RREP with a smaller hop count. The route is kept in the
routing table as long as it is needed. AODV also uses sequence
numbers to ensure the freshness of routes. If a link failure of
an active route occurs, the node upstream of the break propagates a route error (RERR) message to the source node to notify the event of an unreachable destination. After receiving the
RERR, the source node reinitiates route discovery to resume data
transmission.
AODV has the advantages of loop-free, self-starting, and scalability. However, AODV cannot ensure the reliability of the
transmitted data. Therefore, we improve the reliability of AODV
by introducing the capability of anycast routing. In addition, we
deploy multiple data receivers in a WMN. With the anycast
routing, the source node can communicate with the closest data
receiver. We further use a hybrid approach that combines the
mechanism of reliable data transmission with anycast routing to
achieve efficient route recovery.
Our protocol has five message types, including RREQ, RREP,
RERR, DATA, and acknowledgment (ACK). The first three messages, RREQ, RREP, and RERR, are inherited from AODV and
are used to maintain the routing information. The DATA message is only transmitted after an active route to the data receiver
is discovered. When the data receiver receives a complete DATA
message, it sends an ACK message back to the source node. We
show the format of our DATA message in Fig. 2, where the
DATA message is stored in the 802.15.4 MAC data payload.
We use 1 B for event indicator to identify one of the critical
events. The patient ID shows the identifier of the source node.
The router ID indicates the identifier of the router node, which
is closest to the source node. This field is used to achieve indoor positioning, as described in Section IV. The last field, raw
data, stores optional 50-B ECG raw data. Next, we describe the
operations of each type of nodes.

Fig. 3.

State transition diagram of the sensor node.

The operations of a sensor node are described as follows.

When a sensor module acquires vital signs, it informs the ZigBee module to check whether it has the route information to the
data receiver. If yes, then the ZigBee module transmits packets
to a data receiver. Otherwise, the ZigBee module encapsulates
an RREQ message into a frame and broadcasts the frame to the
neighboring router nodes. When the ZigBee module receives an
RREP packet, it adds route record to its routing table for the data
receiver. If the ZigBee module receives more than one RREP
packet, the data receivers specified in the extra RREP packets
are stored in the DataReceiver list. With an active route, the
sensor module could periodically sample vital signs and store
these data in the buffer of the ZigBee module. Once the buffer
of the ZigBee module is full, the ZigBee module encapsulates
the data into a DATA message for transmission. After sending
a DATA message, the ZigBee module periodically checks the
ACK message from the data receiver. When the ZigBee module
receives an ACK message, it removes the acknowledged data.
If the ZigBee module receives an RERR message or the ACK
message is not received within a timeout period, it checks its
DataReceiver list. In the case that the DataReceiver list is not
empty, the first entry in the DataReceiver list is retrieved and
inserted into the routing table. The DATA message is then retransmitted to the new data receiver. If the DataReceiver list is
empty, then the ZigBee module will retransmit RREQ packet to
discover a new route. We show the state transition diagram of
the sensor node in Fig. 3.
B. Router Node

A. Sensor Node
In a sensor node, there are two modules: sensor and ZigBee.
Both modules are connected through an RS-232 interface. The
patient or elder is equipped with a sensor node to acquire vital
signs from the sensor module. The vital signs are then encapsulated in packets and transmitted by the ZigBee module. Since a
sensor node is mobile, the path to the data receiver could change
arbitrary. Each ZigBee module has a DataReceiver list to store
the addresses of the data receivers notified from the received
RREP messages and the next hops to the corresponding data
receivers.

The router node provides the functions of route maintenance

and packet relaying; hence, it only has a ZigBee module. When
a router node receives an RREQ packet, it checks whether it has
the route record for the queried destination node. If yes, then it
replies with an RREP message to the sensor node. Otherwise, the
RREQ message is rebroadcasted to its neighbors. Each router
node uses a counter, AnycastGate, to record the number of the
received RREP messages. The counter also indicates the number
of data receivers, which can be contacted through the router
node. The router node also has a DataReceiver list for storing
the data receivers notified from the received RREP messages.

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IEEE TRANSACTIONS ON INFORMATION TECHNOLOGY IN BIOMEDICINE, VOL. 16, NO. 1, JANUARY 2012

When the router node receives an RREP message, it increases its

AnycastGate counter by one. The corresponding data receiver
is also inserted into DataReceiver. If the counter equals one,
the route record is generated for the data receiver specified in
the RREP message. The RREP message is then forwarded to
the sensor node. Otherwise, the RREP message is discarded.
The route record is then used for relaying DATA messages. The
transmitted DATA messages are kept in the DATA buffer of the
ZigBee module before receiving an ACK message. If the ACK
message is not received in a timeout period, a new data receiver
is selected for retransmission.
The operations of the router device are described as follows.
When the router node receives an RREQ packet, it checks the
RREQ message in the receiving buffer to determine whether
it has received a new RREQ message. If yes, then the router
node adds route record for the source node to its routing table. It also broadcasts the RREQ message to its neighboring
nodes. When a router node receives an RREP packet, it stores
the data receiver address into a DataReceiver list and augment
its AnycastGate counter by one. If the counter is larger than
one, then the router node discards this RREP packet directly.
Otherwise, the router node adds a route record for the destination node to its routing table. With the AnycastGate counter,
the subsequent RREP messages for the same destination node
would be discarded since the first RREP message usually corresponds to the route of the nearest data receiver to fulfill the
requirement of anycast routing. When a DATA message is received, its forward address is used to screen for the router node.
If no, the router node relays the DATA message to downstream
according to its routing table. The DATA message is also stored
in the buffer of the ZigBee module for the requirement of reliability. Otherwise, the DATA is received and the packet is
discarded. This router will periodically monitor the ACK message. When the router device receives an ACK message, it removes the acknowledged DATA message from its buffer. If
the ACK message is not received within a predefined timeout
period or an RERR message is received, then the router device deletes the route record of the destination node from its
routing table and DataReceiver list. The value of AnycastGate
counter is decreased by one. If the value of AnycastGate is still
larger than zero, there is at least one another data receiver in the
DataReceiver list. The router node then retransmits the DATA
message to the new data receiver. Otherwise, an RERR message is created and transmitted to the source node. The state
transition diagram of the router node is shown in Fig. 4. The
pseudo code of processing message in router node is shown in
Fig. 15.
We note that although the router node only forward the first
RREP message to the sensor node, the sensor node might still
receive more than one RREP message. Consider a WMN with
daisy-chained router nodes and two data receivers located at
both ends. For a sensor node located between two router nodes,
its RREQ message is forwarded by both router nodes. Both
data receivers will receive the RREQ message and reply with
an RREP message. Consequently, the sensor node receives two
RREP messages and stores the data receiver of the second RREP
message in the DataReceiver list for improving reliability.

Fig. 4.

State transition diagram of the router node.

Fig. 5.

State transition diagram of the data receiver.

C. Data Receiver
The data receiver is responsible for receiving the DATA messages through a ZigBee module and extracts data to the computer
through a USB interface, which emulates an RS-232 port. The
interface also provides dc power to the data receiver.
The operations of the data receiver are described as follows.
When the data receiver receives an RREQ packet, it checks the
RREQ message in the receiving buffer to determine whether
this is a new RREQ message. If yes, then the data receiver adds
route record for the sensor node in its routing table. Meanwhile,
it sends an RREP message to the sensor node. It extracts vital
signs from the received DATA message. The extracted vital signs
are transmitted to the computer through the USB interface. The
data receiver also uses a timer to trigger the transmission of ACK
messages for the sensor node. The state transition diagram of the
data receiver is shown in Fig. 5. The pseudo code of processing
message in data receiver node is shown in Fig. 16.
The proposed reliable transmission protocol is essentially a
hybrid solution, which merges the routing algorithm with reliable data transmission. This hybrid approach offers the advantages of better efficiency. With the anycast routing, the sensor
node can transmit vital signs to the nearest data receiver. Unlike
the traditional end-to-end approach of reliable data transmission,
our protocol can provide fast rerouting and retransmission. As

CHEN et al.: A RELIABLE TRANSMISSION PROTOCOL FOR ZIGBEE-BASED WIRELESS PATIENT MONITORING

Fig. 7.

Fig. 6.

Fall detection algorithm.

a result, the latency of data transmission can be shortened while

the data reliability can be maintained.
IV. FALL MONITORING SYSTEM
Advances in ubiquitous computing technologies have successfully supported the applications of location-based service
that can know where incidents happened and give responses
immediately. From the perspective view of patient monitoring,
an accident detection system such as a fall monitoring system
can provide good supervising assistance on patient care. However, it is crucial to avoid the vital signs missing, especially,
a fall event because it may be mortal to the patients. Based
on the reliable forwarding scheme for ZigBee wireless sensor
networks, we propose a region-based location awareness fall
detection system. This system includes three parts: fall detection scheme [23], region-based indoor position procedure, and
an ECG sensor. When a fall event is detected, a 4-s ECG data
is also transmitted through the proposed protocol to achieve the
purpose of reliable transmission.
In the first part, we focus on home incidents of falls caused
by accidents such as faint or weakness. The mobile device with
a 5 G triaxial accelerometer is placed on waist to measure triaxial accelerations with 200 Hz sampling. According to sensors
orientation, the x-axis is frontal direction, the y-axis is vertical side, and the z-axis equals to sagittal side. The algorithm is
shown in Fig. 6. First, it calculates SV Ma (sum vector magnitude of accelerations) continuously. As soon as the value of
SV Ma is larger than 6 G, the fall detection scheme will give
alarm directly because the values of SV Ma on daily activities
are all under 6 G [24]. If the value of Sh (acceleration on the

11

Signaling of region-based indoor location procedure.

horizontal) is bigger than 2 G, that means the body tilts forward

or backward acutely. Then it will use continuous 0.3 s stable
SV Ma within 2 s to estimate whether the faller is at rest or not.
If the faller is at rest, it will integrate Vref (reference velocity)
during the falling duration. Finally, the proposed fall detection
scheme will give alarm when the value of Vref is over 1.7 m/s.
We classify falls into eight major types and select seven types
of daily movements to verify that the system would misdetect
the daily activities as falls or not.
As soon as a fall has happened, the system will start the regionbased indoor position procedure that includes four stages, as
shown in Fig. 7.
1) The mobile device broadcast a message to the wireless
routers which can be reached by signal strength indicator
(RSSI) signal.
2) These wireless routers feed back the RSSI values that they
have received.
3) The mobile device transmits the fall alarm to the wireless
router that received the largest value before.
4) This wireless router fills its own short MAC address in the
router ID field of DATA message (see Fig. 2) to indicate
that the fall event happened in this region. The DATA
message is then sent to a data receiver.
After a fall event is detected, 4-s ECG data is also transmitted
to the data receiver and shown on the GUI display. Monitoring the subjects heart rate and possible cardiac event, such
as sinus tachycardia, sinus bradycardia, premature ventricular
contraction (VPC), and short-run ventricular tachycardia (VT) is
helpful in emergency response for heart attack of unintentional
falls. Moreover, some diseases cause large change in heart rate
like cardioinhinitory carotid sinus hypersensitivity would induce
nonaccidental falls [25]. Therefore, the 4-s ECG data can not
only help the caregivers to know the urgency of the fall-induced
injury, but also show the probable reasons of falls.

V. SIMULATION AND IMPLEMENTATION RESULTS

We evaluate the performance of our scheme by using a network simulator and practical implementation. In the performance evaluation based on a network simulator, we demonstrate
the scalability of our scheme with respect to the number of wireless nodes. Next, we show the prototype of our fall monitoring
system to demonstrate the feasibility of our scheme. We also

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Fig. 8.

IEEE TRANSACTIONS ON INFORMATION TECHNOLOGY IN BIOMEDICINE, VOL. 16, NO. 1, JANUARY 2012

Control overhead.

Fig. 9.

Average search latency.

measure the end-to-end transmission delay through a cellular

network and the power consumption of our wireless nodes.
A. Simulation Results
We start from the simulator-based performance evaluation.
The evaluation was conducted by using the IEEE 802.15.4
model in the INET framework of a publicly available network
simulator, OMNet++ [26]. The size of the simulation area is
1000 600 m2 . The performance metrics include control overhead, search latency, transmission latency, and delivery ratio.
The control overhead shows the total number of the request and
reply packets. The search latency is the time period from sending the RREQ message until receiving the first RREP message.
The transmission latency is the time period for a DATA message from the sensor node to its data receiver. The delivery ratio
indicates the percentage of the successfully transmitted DATA
messages. We vary the number of wireless nodes from 30 to
50 and the number of data receivers from 2 to 10 to show the
impact of node densities. We also relate our simulation results
to the broadcast and multicast schemes as a comparison.
We consider the control overhead of our scheme first. For each
scheme, the solid line indicates the number of control messages
with 40 wireless nodes. For a specific number of data receivers,
the control overhead for the network with 30 nodes is denoted
as  and that with 50 nodes is denoted as . Both symbols are
shown on the end of the dotted line, as illustrated in Fig. 8. The
results show that for all schemes, the control overhead raises as
the number of wireless nodes increases. When the number of
data receivers is small, the difference of control overhead between our scheme and the multicast scheme is negligible. The
difference multiplies as the number of data receivers increases
since the control overhead of the multicast scheme is proportional to the number of data receivers. Therefore, the control
overhead of the multicast scheme is close to that of the broadcast scheme. Among these three schemes, the broadcast scheme
consistently has the highest control overhead and our scheme
has the least. When the number of data receivers increases to
10, our scheme generates 33% less control messages than that
of the broadcast and multicast schemes. Since anycast routing
only communicates with the closest data receiver, our scheme
has the least control overhead as well as energy consumption.

Fig. 10.

Average transmission latency.

Next, we show the average search latency of the service requests in milliseconds with different number of nodes and data
receivers in Fig. 9. Similar to Fig. 8, we also show the experimental results with 30 and 50 nodes by  and on the end
of the dotted lines, respectively. In a WMN with more wireless
nodes, the path to the destination nodes is usually prolonged to
increase the transmission latency. For the broadcast and multicast schemes, their search latencies vary from 10 to 14 ms for
different network size. Both schemes have significantly higher
search latency than our scheme since their source node must
wait for reply messages from all data receivers. Our scheme, by
contrast, shortens the search latency by only finding the closest data receiver. The search latency can be improved with more
data receivers since the distance between the source node and the
closest data receiver can be reduced. For the case with 40 nodes
in a WMN, the search latency reduces from 9.2 to 8.6 ms when
the number of data receivers increases from 2 to 10. Therefore,
we can improve the search performance of our scheme by employing more data receivers. Although this approach also results
in more control overhead, the reduced search latency makes our
scheme suitable for transmitting emergency alerts.
We show the end-to-end transmission delay of a DATA message for different network size in Fig. 10. For each network
size, we show three transmission latencies for different situations. The first transmission latency (init) denotes the time
period from finding the first data receiver and transmitting
DATA packet without link failure. Next, we consider the performance of rerouting for our scheme with a link or node failure

CHEN et al.: A RELIABLE TRANSMISSION PROTOCOL FOR ZIGBEE-BASED WIRELESS PATIENT MONITORING

Fig. 11.

Average packet delivery ratio.

(rerouting), where the router node reroutes DATA message to a

new data receiver in the DataReceiver list. If the rerouting procedure cannot find another available data receiver, the source
node reinitiates the procedure of searching for available data
receivers. In this case, we denote the transmission latency as
researching. These transmission latencies for the network with
40 nodes are denoted by the solid lines and those with 30 and
50 nodes are denoted as  and on the end of the dotted lines,
respectively. As shown in Fig. 10, the init latency is the shortest
since we use anycast to find the closest data receiver. When a
node/link failure occurs to cause a timeout, the router node activates the rerouting procedure. It selects next data receiver from
its DataReceiver list and forward the stored packets to the new
data receiver. Since the packet retransmission is activated from
a router node, the rerouting latency is shorter than the latency
of end-to-end packet retransmission. When there are eight data
receivers, our rerouting scheme increases by only 1 ms to the init
latency. The researching latency is the longest since the source
node must retransmit RREQ messages to find available data receivers and resend packet to the new receiver. In the case with
only a few data receivers, the rerouting latency is increased since
the distance between these data receivers are prolonged. Thus,
the difference between the rerouting and researching latencies
is reduced.
Finally, we show the performance of average packet delivery ratio in Fig. 11. When there is only one data receiver, our
scheme has the same performance as the broadcast scheme.
However, delivery ratio of our scheme achieves 100% with two
data receivers. By using fast rerouting, our scheme can effectively reroute DATA messages to a new data receiver when a
link/node failure occurs. Both broadcast and multicast schemes
require three data receivers to assure data reliability. By jointly
considering the control overhead, our scheme has the best feasibility than the other schemes.
B. Implementation Results
We implement our reliable anycast routing protocol with ZigBee modules to measure the performance in practice. The prototype of the sensor node is shown in Fig. 12. We use two micro
control units (MCUs, TI MSP430F1611 [27]) in the sensor node,
one for sensor module and the other for ZigBee module. The
sensor module includes a triaxial accelerometer and an ECG
sensor, as shown in Fig. 12(a). The MCU in the sensor module

13

also carries out the procedure of region-based indoor location.

The four ECG patches in the back side of the sensor node are
shown in Fig. 12(b), and the emergency button in the front side
is shown in Fig. 12(c). The ZigBee module uses a low-power
2.4 GHz transceiver, Ubec UZ2400 [28]. Both the router nodes
and data receiver use the same ZigBee module.
We employ seven ZigBee modules to build a home physiological monitoring environment, where six modules act as
router nodes and one module acts as a data receiver, as shown
in Fig. 1. The data receiver is connected to a terminal with a
WWAN module through an RS-232 interface. When the sensor
node detects a fall event, it determines the location of the sensor
node by using the indoor location procedure. Then, it sends a
fall event message with the address of the closest router node to
the data receiver by using the proposed anycast routing protocol.
The sensor node also generates and transmits 4-s ECG signals.
The ECG sensor produces 200 samples per second, and each
sample is 1 B. Therefore, the total ECG data is 800 B. When
the data receiver receives the fall event message, it forward the
message to healthcare professional through a WWAN module
of LTE/WiMAX.
The healthcare professional receiving the fall event message
with the patient location and ECG signals can display the patient
information through a computer software, as shown in Fig. 13.
The software also automatically detects the abnormal ECG signals that include sinus bradycardia, sinus tachycardia, VPC, and
short-run VT. For example, a tachycardia event is detected when
patients heart rate is over 100 beats per minute. The healthcare
professional thus can determine whether an emergency medical
care is carried out. The geographical location of the patient can
be retrieved from the WWAN positioning. By combining the
indoor location, the medical staff can access the patient as soon
as possible.
We measure the power consumption of the ZigBee module for different operations. In normal conditions, the ZigBee
module enters sleep mode for power saving, where the power
consumption is merely 0.7 mA. When the sensor module detects an abnormal event, the ZigBee module is woken and enters
standby mode (22.4 mA). The power consumption for receiving and transmitting packets varies between 26.6 and 28.4 mA.
There are three LEDs for debugging in the prototype of our
sensor node. Our results show that each LED consumes 2.42.8
mA. With the power consumption of the sensor node, we can
estimate the device lifetime for a given battery capacity. The battery capacity is measured in milliamps hours (mAH). Since the
average power consumption of node communication is about 27
mA (without blinking LEDs), an AAA battery with 800 mAH
can drive the ZigBee module to continuously transmit packets
for nearly 30 h.
In the last experiment, we evaluate the end-to-end delay
time of the transmission fall event and ECG signals through
a three-hop ZigBee network and a cellular network. We use
three difference generations of cellular networks, 2.5G(GPRS),
3G(UMTS), and 4G(WiMAX), in our experiments. Since the
sensor node cannot provide exact time period of transmitting
a data packet, the latency is retrieved by connecting the sensor
node to the terminal computer of receiving ECG signals from the

14

Fig. 12.

IEEE TRANSACTIONS ON INFORMATION TECHNOLOGY IN BIOMEDICINE, VOL. 16, NO. 1, JANUARY 2012

Prototype of sensor node. (a) Compose of sensor node. (b) Back of sensor node. (c) Front of sensor node.

Fig. 14.

Fig. 13. Screen shot of the fall detection event with the patient location and
ECG signals in the fall monitoring software.

Internet. There is another computer to connect the ZigBee module of data receiver. This computer is equipped with a cellular
modem for transmitting ECG signals to the terminal computer.
For the purpose of comparison, it is also equipped with a 2G
(GSM) modem for transmitting SMS. When the data receiver
receives a fall event, the connecting computer will send 4-s
ECG signals (800 B) through a cellular network and an SMS of
fall event through a GSM cellular network simultaneously. The
ECG data passes through the cellular network and the Internet,
then arrives the terminal computer. Both interfaces between the
computers and ZigBee modules are USB-emulated RS232 ports
(115 200 bits/s).
The experimental results of the end-to-end transmission delay
are shown in Fig. 14. The average time for transmitting the SMS
message is about 39.1 s, where the delay from SMS module to
cell phone consumes 35 s and the transmission delay of our
three-hop ZigBee network consumes 3.3 s. For the packets of
ECG signals transmitted through a cellular network, the average
transmission time with GPRS is about 23.3 s, where the dial-up
delay and transmission delay are both 10 s. The average transmission time with universal mobile telecommunications system
(UMTS) is improved to 9.3 s, which includes 5 s dial-up delay
and 1 s transmission delay. The average transmission time with
WiMAX is further reduced to about 4.3 s. Since WiMAX en-

End-to-end transmission delay through a ZigBee/Cellular network.

ables data transmission in default, there is no dial-up delay. The

transmission of ECG data consumes less than 1 s. Thus, we conclude that the 4G technology significantly improves the richness
of patient information with a shorter transmission latency.

VI. CONCLUSION
This paper presents a reliable anycast routing protocol for
ZigBee-based wireless patient monitoring. For a mobile sensor node, the new scheme selects the closest data sink as the
destination in a WMN. Therefore, the latency of route query
and the number of control messages can be reduced simultaneously. The new protocol also has the capability of fast rerouting.
Therefore, a broken path can be recovered in a short latency, and
the reliability of the transmitted vital signs can be assured. We
implement a ZigBee-based prototype of fall monitoring system
based on the new routing protocol. In the system, we integrate
a triaxial accelerometer and an ECG sensor to achieve real-time
fall detection and physiologic monitoring. When a fall event is
detected, the closest router node to the sensor node is calculated.
In addition, 4-s ECG signals are transmitted to the healthcare
professional for notifying the patient status. The system can
be combined with the next generation WWAN, such as LTE
or WiMAX, to achieve pervasive healthcare. Through the integration with WiMAX, we demonstrate that our scheme can
improve the feasibility of wireless patient monitoring systems.

CHEN et al.: A RELIABLE TRANSMISSION PROTOCOL FOR ZIGBEE-BASED WIRELESS PATIENT MONITORING

APPENDIX

Fig. 15.

Pseudocode of processing message in router node.

Fig. 16.

Pseudocode of processing message in data receiver node.

REFERENCES
[1] K. Kinsella and W. He, An aging world: 2008, International Population
Reports, U.S. Census Bureau, Washington, DC, Tech. Rep. P95/09-01,
2009.
[2] Y. Gu, A. Lo, and I. G. Niemegeers, A survey of indoor positioning
systems for wireless personal networks, IEEE Commun. Surv. Tutorials,
vol. 11, no. 1, pp. 1332, First Quarter 2009.
[3] H. Liu, H. Darabi, P. Banerjee, and J. Liu, Survey of wireless indoor
positioning techniques and systems, IEEE Trans. Syst., Man Cybern. C,
Appl. Rev., vol. 37, no. 6, pp. 10671080, Nov. 2007.
[4] L. Liu, E. Manli, Z. Wang, and M. Zhou, A 3d self-positioning method
for wireless sensor nodes based on linear FMCW and TFDA, in Proc.
2009 IEEE Int. Conf. Syst., Man Cybern.. Piscataway, NJ: IEEE Press,
2009, pp. 29902995.

15

[5] L. Liu, Z. Wang, and M. Zhou, An innovative beacon-assisted bi-mode

positioning method in wireless sensor networks, in Proc. Int. Conf. Netw.,
Sens. Control, Mar. 2009, pp. 570575.
[6] J. S. Choi and M. Zhou, Performance analysis of Zigbee-based body
sensor networks, in Proc. IEEE Conf. Syst., Man Cybern., 2010, pp.
24272433.
[7] K. M. Hanna, N. Natarajan, and B. N. Levine, Evaluation of a novel
two-step server selection metric, in Proc. 9th Int. Conf. Netw. Protocols.
Washington, DC: IEEE Computer Society, 2001, pp. 290300.
[8] H. Miura and M. Yamamoto, Server selection policy in active anycast,
in Proc. 2001 Asia-Pasific Conf. Commun. (APCC 2001), Tokyo, Japan,
Sep. 2001, pp. 648651.
[9] S.-K. Chen and P.-C. Wang, An anycast-based emergency service for
healthcare wireless sensor networks, IEICE Trans., vol. 93-B, no. 4,
pp. 858861, 2010.
[10] M. Chen and W. Mao, Anycast by DNS over pure IPv6 network, University of California, Berkeley, Project Rep., 2001.
[11] S.-K. Chen and P.-C. Wang, Design and implementation of an anycast
services discovery in mobile ad hoc networks, ACM Trans. Auton. Adapt.
Syst., vol. 6, pp. 2:12:9, Feb. 2011.
[12] B. Engel, R. Engel, R. Haas, D. Kandlur, V. Peris, and D. Saha,
Using network layer anycast for load distribution in the internet, IBM T.J. Watson Research Center, Hawthorne, NY, Tech. Rep.,
RC 20938, 1997.
[13] J. Wang and X. Lu, Route recovery based on anycast policy in mobile
ad hoc networks, in Proc. Int. Conf. Commun. Technol., 2003, vol. 2,
pp. 12621265.
[14] C. Partridge, T. Mendez, and W. Milliken, Host anycasting service,
Internet RFC 1546, Nov. 1993.
[15] X. Wang and H. Qian, Design and implementation of anycast services
in ad hoc networks connected to IPv6 networks, J. Netw., vol. 5, pp.
403410, 2010.
[16] Y. Li, S. Peng, and W. Chu, An efficient distributed broadcasting algorithm for wireless ad hoc networks, in Proc. 6th Int. Conf. Parallel
Distrib. Comput. Appl. Technol. Washington, DC: IEEE Computer Society, 2005, pp. 7579.
[17] U. Varshney, Improving wireless health monitoring using incentive-based
router cooperation, Computer, vol. 41, pp. 5662, May 2008.
[18] E. Jovanov, A. ODonnel, A. Morgan, B. Priddy, and R. Hormigo, Prolonged telemetric monitoring of heart rate variability using wireless intelligent sensors and a mobile gateway, in Proc. Eng. Med. Biol., 24th Annu.
Conf. Annu. Fall Meet. Biomed. Eng. Soc. EMBS/BMES Conf., 2002. Proc.
2nd Joint, oct. 2002, vol. 3, pp. 18751876.
[19] R. S. H. Istepanian and A. A. Petrosian, Optimal zonal wavelet-based
ecg data compression for a mobile telecardiology system, IEEE Trans.
Inf. Technol. Biomed., vol. 4, no. 3, pp. 200211, Sep. 2000.
[20] U. Varshney and S. Sneha, Patient monitoring using ad hoc wireless
networks: Reliability and power management, IEEE Commun. Mag.,
vol. 44, no. 4, pp. 4955, Apr. 2006.
[21] D. Cypher, N. Chevrollier, N. Montavont, and N. Golmie, Prevailing
over wires in healthcare environments: benefits and challenges, IEEE
Commun. Mag., vol. 44, no. 4, pp. 5663, Apr. 2006.
[22] C. E. Perkins and E. M. Royer, Ad-hoc on-demand distance vector routing, in Proc. 2nd IEEE Workshop Mobile Comput. Syst. Appl., New
Orleans, LA, Feb. 1999, pp. 90100.
[23] C.-N. Huang, G.-C. Chen, C.-Y. Chiang, J.-S. Chang, S. J. Hsu, W.-C. Chu,
and C.-T. Chan, Fall detection system for healthcare quality improvement
in residential care facilities, J. Med. Biol. Eng., vol. 30, no. 4, pp.
247252, 2010.
[24] C. V. Bouten, K. T. Koekkoek, M. Verduin, R. Kodde, and J. D. Janssen, A
triaxial accelerometer and portable data processing unit for the assessment
of daily physical activity, IEEE Trans. Biomed. Eng., vol. 44, no. 3,
pp. 136147, Mar. 1997.
[25] R. A. Kenny, D. A. Richardson, N. Steen, R. S. Bexton, F. E. Shaw, and
J. Bond, Carotid sinus syndrome: A modifiable risk factor for nonaccidental falls in older adults (safe pace), J. Amer. Coll. Cardiol., vol. 38,
no. 5, pp. 14911496, 2001.
[26] OMNeT++ Community Site. [Online]. Available: http://www.omnetpp.
org/ (Accessed 2010)
[27] TI MSP430F1611 datasheet. [Online]. Available: http://focus.ti.com/docs/
toolsw/folders/print/msp430-3p-tegh-cm1611-devbd.html#Features
[28] Ubec UZ2400 datasheet. [Online]. Available: http://www.coretk.com/
CataLog/cata_img/FILE/183366731/UBEC/168/168_176_1146034480.
pdf

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IEEE TRANSACTIONS ON INFORMATION TECHNOLOGY IN BIOMEDICINE, VOL. 16, NO. 1, JANUARY 2012

Shyr-Kuen Chen received the Ph.D. degree from the

Department of Computer Science and Engineering,
National Chung Hsing University, Taichung, Taiwan,
in 2011.
He is currently a Senior I/T in Aerospace Industrial Development Co., Ltd., where he is engaged in
research on network management and software development. His research interests include mobile ad
hoc networks, wireless sensor networks, and anycasting protocols.

Tsair Kao received the Ph.D. degree in electrical

engineering from the University of Michigan, Ann
Arbor, MI, in 1984.
From 1989 to 2008, he was with the faculty of
Biomedical Engineering, National Yang-Ming University. Since 2009, he has been a Professor of
Biomedical Engineering at Hungkuang University,
Taichung, Taiwan. His research interests include
automated analysis of bioelectrical signals, digital signal processing, and computer applications in
medicine.

Chia-Tai Chan received the Ph.D. degree in computer science and information engineering from National Chiao Tung University, Hsinchu, Taiwan, in
1998.
From 1999 to 2005, he was a Project Researcher
with Telecommunication Laboratories Chunghwa
Telecom Co., Ltd. Since August 2005, he has been an
Associate Professor with the faculty of the Institute of
Biomedical Engineering, National Yang-Ming University, Taipei, Taiwan. His research interests include
sensor networks, context-aware computing, ubiquitous computing, pervasive healthcare, networking, and communication technologies.

Chih-Ning Huang received the B.S. degree from the

Department of Electronic Engineering, National Central University, Taoyuan, Taiwan, in 2007. She is currently working toward the Ph.D. degree at the Institute of Biomedical Engineering, National Yang-Ming
University, Taipei, Taiwan, since 2008.
Her research interests include fall detection, indoor positioning, and elderly healthcare.

Chih-Yen Chiang is currently working toward the

Ph.D. degree at the Institute of Biomedical Engineering, National Yang-Ming University, Taipei, Taiwan,
since 2008, under the supervision of Dr. Chia-Tai
Chan.
His research interests include patient control analgesia, activity recognition, abnormality detection,
and ubiquitous computing.

Chin-Yu Lai received the M.S. degree in computer

science and engineering from National Chung Hsing
University, Taichung, Taiwan, in 2011.
He is current an R&D Engineer at Gemtek Technology Co., Ltd., where he he is engaged in research
on voice over Internet Protocol equipment development.

Tse-Hua Tung received the B.E. degree in biomedical engineering from Chung Yuan Christian University, Chung Li, Taiwan, in 2004, and the M.S. degree
in biomedical engineering from National Yang-Ming
University, Taipei, Taiwan, in 2007, where he currently working toward the Ph.D. degree in Biomedical Engineering.
From 2008 to 2010, he was a Physics Experiment Teaching Assistant with the faculty of the Institute of Biomedical Engineering, National Yang-Ming
University. His research interests include pervasive
healthcare and hard copy ECG signal digitizing

Pi-Chung Wang received the M.S. and Ph.D. degrees in computer science and information engineering from National Chiao Tung University, Hsinchu,
Taiwan, in 1997 and 2001, respectively.
From 2002 to 2006, he was with Telecommunication Laboratories of Chunghwa Telecom, where
he was engaged in research on network planning in
broadband access networks and public switched telephone network migration, and IP lookup and classification algorithms. Since 2006, he has been an Assistant Professor of Computer Science at National
Chung Hsing University, Taichung, Taiwan, where he is currently an Associate
Professor. His research interests include IP lookup and classification algorithms,
scheduling algorithms, congestion control, and application-driven wireless sensor networks.