Received: 19 December 2020 Revised: 15 May 2021 Accepted: 21 June 2021

DOI: 10.1111/exsy.12765

ORIGINAL ARTICLE

Design of a secured telehealth system based on multiple

biosignals diagnosis and classification for IoT application

Hocine Hamil1,2,3 | Zahia Zidelmal1 | Mohamed Salah Azzaz2 | Samir Sakhi2 |

Redouane Kaibou2 | Salem Djilali2 | Djaffar Ould Abdeslam3

1
Laboratoire d’Analyse et Modélisation des
Phénomènes Aléatoires (LAMPA), Faculté de Abstract
Genie Electrique et Informatique, The aim of this article is to design a new telehealth system with secured wireless
Departement d’Electronique, Université
Mouloud Mammeri de Tizi-Ouzou, Tizi-Ouzou, transmission and classification of multiple biosignals using e-Health sensors platform
Algeria and Xbee modules with Arduino Uno and Raspberry Pi as acquisition and processing
2
Laboratoire Systèmes Electroniques et

units, respectively. The collected data, such as temperature, airflow, position, Gal-
Numériques, Ecole Militaire Polytechnique,
Bordj El-Bahri, Algeria vanic skin response and oxygen in the blood can be evaluated in order to monitor
3
Institut RIMAS, Université de Haute-Alsace, patient health state using threshold detection. The prediction of the cardiac state
Mulhouse, France
based on automatic identification of arrhythmias is validated by the classification of
Correspondence ElectroCardioGram (ECG) signals using Artificial Intelligence (AI) by exploiting Ten-
Mohamed Salah Azzaz, Laboratoire Systèmes


Electroniques et Numériques, Ecole Militaire sorFlow and Keras tools. Different AI algorithms and a combination with different
Polytechnique, BP 17 Bordj El-Bahri, Algiers, Machine Learning (ML) basing to transfer learning approach are tested. These algo-
Algeria.
Email: ms.azzaz@gmail.com rithms include Artificial Neural Network (ANN), Convolutional Neural Network
(CNN), Support Vector Machine (SVM), K-Nearest Neighbour (KNN) and Random
Forest (RF). At first, ANN and CNN are used to classify ECG-scalogram images using
softmax, then the used CNN model (VGG16) is employed to extract features and pass
them to other traditional classifiers (SVM, KNN and RF) allowing to evaluate and
BISWAJEET select the best classifier, such that the ECG signal can be classified into four catego-
CHAMPATY
2022.06.19 ries namely Normal Sinus Rhythm (NSR), Atrial Fibrillation (AF), Congestive Heart
23:59:25 +05'30' Failure (CHF) and other cardiac arrhythmia (ARR). The proposed method has been
evaluated using real recorded signals and four PhysioNet databases. A Graphical User
Interface (GUI) has been designed with C# under Visual Studio IDE allowing to display
the results using personal computer (PC) or a network linked phone, which makes it
possible to transfer the diagnosis with the prediction results to a remote clinic control
room as Internet of Things (IoT) system application. The best classification accuracy
of 99.56% is attained, confirming that the designed system allows a good trade-off
between low cost and performances in addition, it is easy to use with quick access to
multiple biosignals. It has improved vital characteristics monitoring and diagnosis ser-
vices quality under a robust secured wireless transmission using lightweight chaos-
based algorithm, thus preventing loss of life during critical health situations.

KEYWORDS
artificial intelligence, biosignals, chaos encryption, diagnosis, e-health, wireless transmission

Expert Systems. 2021;e12765. wileyonlinelibrary.com/journal/exsy © 2021 John Wiley & Sons Ltd. 1 of 27
https://doi.org/10.1111/exsy.12765
2 of 27 HAMIL ET AL.

1 | I N T RO DU CT I O N

Research in medical fields is very relevant to clinical advances where the development of a sophisticated healthcare systems based on biosignals
analysis with automated anomaly recognition, has been a highly popular topic in the health informatics community. Nowadays, eHealth and
mHealth systems allow to increase the quality of life by providing healthcare services at distance avoiding contamination during COVID-19 pan-
demic (Behar et al., 2020) which helps to protect both patients and front-line health professionals and reduce the mortality and morbidity rates
especially for maternal and elderly people by having a face to face consultations when this is clinically necessary.
In this context, different systems have been presented for automatic and intelligent medical diagnostic where the use of machine learning
plays a very crucial role in assisting clinicians at the point of care. Today, medical, defence and consumer applications have become more sophisti-
cated than before.
As shown in Figure 1 different applications of eHealth monitoring system have been presented in the literature with the aim of ensuring the knowl-
edge of current health status and the accurate location among which we can cite: Real-time Mountain Climber Monitoring in which it is strongly rec-
ommended to be located and monitored continuously, Secure Health Monitoring and tracking of soldiers during the operations under different
geographical conditions (Kulkarni and Kulkarni, 2019); Real-time health monitoring system of remote patient (Lin et al., 2006; Zheng et al., 2020).
With the development of Internet of Things (IoT) technologies, smart wearable devices ensure an accurate collection and analysis of health
indexes in real-time by indicating the present status of wearers and prevent themselves from eventual diseases.
Artificial Intelligence (AI) has found application in many medical branches namely: oncology, dermatology, radiology, neurology and cardiology
(Izci et al., 2019; Rai et al., 2013). To develop a very high-performance characterization systems improving accuracy and speed of detection by
taking into account the increasing complexity of algorithms on the signal processing systems; modern methods are investing more and more in
combining several technologies to ensure a sophisticated e-Health systems (expert systems) exploiting the advancement of web services (IoT) for
medical diagnosis. Different systems for real-time patient monitoring have been proposed recently (Hassani et al., 2020; Lin et al., 2006; Randazzo
et al., 2020; Uddin et al., 2017).
Different sophisticated systems for ECG monitoring have been proposed (Islam et al., 2018; Randazzo et al., 2020; Rashid & Khalid, 2019;
Rashkovska et al., 2011; Singh & Malarvili, 2020). The classification of ECG using deep learning is being extensively present in the literature.
Among which many works where Shahidul Islam et al. (2019) and Toral et al. (2019) focus exclusively on biosignals acquisition and transmission
without anomaly automated recognition taking into account the clinical conditions. Also, the majority of methods proposed to secure the medical
data collected using eHealth systems focus on network security (Do et al., 2017) by loading the data without protection. This exposes the
telehealth system to data falsification or even loss by hackers, which can produce damage and reduce the reliability of the system.
According to Chang, Xu, et al. (2019) and Chang, Cao, et al. (2019) the designed system represents a secured telehealth system based on the
collection and accurate analysis of different biosignals under a private wireless transmission (ethical compliant) securing the system from vulnera-
bilities and potential attacks by protecting the collected data before its transmission using a robust integrated technique based on chaos algorithm
(Lorenz) ensuring the safety of users and the privacy of their health indexes (biosignals) from other illegal access from hackers since technical
knowledge towards data protection is a weak point for users and many laws and regulations on ethical issues are ambiguous (Farahani
et al., 2018) proving that the level of acceptance of medical services varies from one country to another.
Telehealth lacks the in-person face-to-face contact that takes place in traditional healthcare delivery. With a virtual and possibly unknown
patient, physicians must try to personalize the telehealth patient as best they can. Ethical medical practice therefore remains focused on the
patient as a whole person who is more than a data set or collection of digital images.
Telehealth will continue to be an essential part of healthcare delivery as patient care delivery becomes more complex and
requires care coordination and information sharing over time and across providers and settings. However, telehealth introduces

FIGURE 1 Major application of the proposed TeleHealthcare system

HAMIL ET AL. 3 of 27

ethical issues due to changes in patient-provider communication patterns, access to care delivery services and how patients interact
with telehealth tools.
According to Chawla (2020), authors focus on Smart healthcare technologies and introduce the usage of Wearable technologies providing
tools for better personal health management, consideration of the major applications of AI and IOT in the field of healthcare is also detailed.
In Xiao et al. (2018), authors investigate the attack model for IoT systems, and review the IoT security solutions based on machine learning
techniques including supervised learning, unsupervised learning and reinforcement learning.
In this context, the proposed method has applied recent and more adequate algorithms based on chaotic encryption of the data in order to
ensure the efficiency of the proposed embedded system by taking into consideration data privacy. This article describes a fully secured and effi-
cient diagnosis using different biosignals with wireless transmission followed by a multi-class classification of each vital characteristic. The main
contributions of this work can be summarized in the following points:

• Design of an efficient telehealth system for biosignals diagnosis and classification.

• Implementation of classification algorithms on a Raspberry Pi 3 model B+ platform.
• Evaluation of different AI and Machine Learning (ML) algorithms for arrhythmia recognition by adopting the transfer learning technique.
• Increasing security by implementing chaos-based data encryption/decryption and its application on wireless end-to-end transmission under
ZigBee protocol.

The article is organized as follows: After a brief introduction and review of the related works, Section 2 describes the proposed system design.
Section 3 presents biosignals diagnosis. Section 4 details the proposed architecture for cardiac arrhythmia recognition. Other bi-signals classifica-
tion is explained in Section 5. Section 6 shows the developed Graphical User Interface (GUI) with its corresponding sequence diagram. Section 7
presents the proposed chaos based encryption to secure transmitted biosignals via wireless link. Experimental results are presented and discussed
in Sections 8 and 9. Section 10 concludes this work and gives some perspectives.

2 | P R OP O SE D S YS TE M D E SI G N

The main idea of this work is to design a full telehealth system for diagnosis and classification using most of the human body biosignals. For this pur-
pose, an e-Health sensors platform designed by Cooking Hacks Company has been plugged on Arduino Uno board in order to collect all the used
biosignals and achieve signal conditioning. The output signals are acquired by this board allowing their display and transmission to a remote position,
which can be a clinic control room. The received signals are processed and then followed by the classification operation using Raspberry Pi with
Broadcom BCM2837B0 Cortex-A53 64-bit SoC @ 1.4 GHz and 1 Go LPDDR2 SDRAM. Classification results are displayed on the doctor PC via a
secured WIFI-link and in a real-time way. A customized GUI under C # is realized to displaying these results. The transmission part is allowed by exe-
cuting a ZigBee protocol on a pair of XBee modules under secured transmission and this by implementing a complete chaos-based encryption/
decryption process. The designed system is depicted in Figures 2 and 3. Figure 4 details the flow chart of the proposed e-Health system.

3 | B I O S I G N A LS D I A G N O S I S

This section presents the used biosignals and the diagnosis process based on the use of eHealth platform with six biosensors for the acquisition
of SPO2, GSR, Temperature, Airflow, ECG and position.

FIGURE 2 Block diagram of realized hardware solution

4 of 27 HAMIL ET AL.

FIGURE 3 Proposed system for medical biosignals diagnostic and classification

FIGURE 4 Flowchart of the proposed architecture

3.1 | Used biosignals

Figure 5 illustrates the used platform and the different biosensors.

HAMIL ET AL. 5 of 27

FIGURE 5 e-Health sensor platform

3.1.1 | ECG biosignal

The cardiac muscle activity is characterized by different physiological signals namely: ElectroCardioGram (ECG), PhonoCardioGram (PCG) and Bal-
listoCardioGram (BCG), revealing the electrical, acoustical and mechanical activity of the heart, respectively. For this work, the choice has been
made on the ECG signals for technology constraint and its well-known waves form allowing us better identification.
As shown in Figure 6, the ECG represents the evaluation of the electrical activity of the heart as a function of time by appending electrodes
in the skin to illustrate the main waves P, QRS and T in normal case assessing the cardiovascular well-being of the repolarization of the atria,
depolarization of the ventricles and re-polarization of the ventricular myocardium, respectively. Any irregularity of heartbeat indicates an abnor-
mality in one’s heart rhythm For example: in atrial fibrillation (AF), the signals in the upper chambers of the heart are chaotic. The atrioventricular
(AV) node representing the electrical connection between the atria and the ventricles is bombarded with impulses trying to get through to the
ventricles, which makes it harder to transport blood to other organs.

3.1.2 | Other biosignals

The used body temperature sensor indicates the temperature value according to the period of day and level of action of the individual. Pulse
Oximetry (model CMS 50DL) is utilized for the observation of oxygen saturation in blood. The used airflow sensor allows us to measure the
breathing rate of a patient in need of respiratory help. The used patient position sensor monitors five different positions with triple-axis acceler-
ometer. Galvanic skin response (GSR) where the skin conductance response sensor measures the psycho galvanic reflex of the body, which is usu-
ally measured in micro Siemens. However, in this work, skin conductance is measured in millivolts (mV).

3.2 | Biosignals diagnosis process

This process starts by the acquisition of the different biosignals using the e-Health sensors platform and Arduino Uno. The position of each sensor
on the human body is illustrated in Figure 7.
6 of 27 HAMIL ET AL.

FIGURE 6 Cardiac cycle with the associated waves of the ECG signal (one-lead) Merone et al. (2017)

FIGURE 7 Position of sensors on the human body: (a) airflow, (b) ECG, (c) position, (d) SPO2, (e) temperature, (f) GSR

4 | P R O P O S E D A R C H I T E C T U R E F O R CA R D I A C A R R H Y T H M I A R E C O G N I T I O N

The proposed approach, illustrated in Figure 8, can be divided into four main stages; the data pre-processing, data segmentation, classification
using at first Artificial Neural Network (ANN) and Convolutional Neural Network (CNN), then CNN as feature extractor combined with traditional
machine learning (Support Vector Machine [SVM], K-Nearest Neighbour [KNN] and Random Forest [RF]) to select the most accurate model for
Normal Sinus Rhythm (NSR), Atrial Fibrillation (AF), Congestive Heart Failure (CHF) and other cardiac arrhythmia (ARR) anomalies. During data
HAMIL ET AL. 7 of 27

a)-ECG signals b)- ECG segementation c)- Signal to image transformation

- MIT-BIH Normal Sinus Rhythm

- BIDMC Congestive Heart Failure
- MIT-BIH Arrhythmia NSR_image CHF_image
NSR_Segment CHF_Segment
- MIT-BIH Atrial Fibrillation
- Acquired real ECG signals

15 % for
85 % for Training phase Testing ARR_image AF_image
ARR_Segment AF_Segment
phase

d)- ECG classification using different machine learning

d.1)- Using ANN

NSR

Dense 200 (Relu)

Dense 300 (Relu)

Dense 300 (Relu)

Dense 200 (Relu)
ECG image

CHF

Softmax
Flatten

AF

ARR

d.2)- Using CNN-Softmax, CNN-SVM, CNN-KNN and CNN-RF

CNN-Softmax
CONV 4-2
CONV 1-2

CONV 3-2
CONV 2-2

POOLING
CONV 2-1
CONV 1-1

POOLING

CONV 4-1
CONV 3-1

CONV 3-3

CONV 5-2
POOLING
POOLING

CONV 4-3

CONV 5-3

POOLING
CONV 5-1

Output
DENSE
DENSE

DENSE
Input

Features extraction approach based on VGG16 model (Transfer Learning) Removed

Extracted Features

Machine Learning

SVM
CONV 4-2
CONV 1-2

CONV 3-2
CONV 2-2

POOLING

Prediction
CONV 2-1
CONV 1-1

POOLING

CONV 4-1
CONV 3-1

CONV 3-3

CONV 5-2
POOLING
POOLING

CONV 4-3

CONV 5-3

POOLING
CONV 5-1
Input

KNN

RF

FIGURE 8 From ECG signals to arrhythmia recognition: (a) ECG signal source, (b) ECG segmentation, (c) ECG signal to image
transformation, (d) ECG classification using CNN and different ML

pre-processing, all ECG signals are denoised, segmented and transformed into scalogram-images. After that, ECG scalogram-images are used as
input images for the ANN, then CNN models. In our approach, VGG16 is used to encode learned features from the fed images. A big advantage
of using a pre-trained CNN model for feature extraction is independence of any training procedure even for the last layers. In other words, the
raw images are only fed forwards to the CNN model. VGG16 has multiple layers and features, which can be used to extract features with different
level of abstraction to be then used by classifiers. In our approach different classifiers are used namely, SoftMax, SVM, KNN and RF. After training
the different classifiers using the training dataset, the classification accuracy is validated using a testing dataset. All stages are detailed by the fol-
lowing sections.
8 of 27 HAMIL ET AL.

FIGURE 9 Schematic of the ECG sensor (integrated on the used eHealth shield

(a) (b)

FIGURE 10 Applying the second order Butter-worth filter for ECG signals: (a) before, (b) after

4.1 | ECG denoising

The first step for data preparation is to filter (Bhardwaj et al., 2016; Qureshi et al., 2017) ECG signals. The ECG signal is reached by different
noises during the acquisition, which correspond to harmonics in the power supply networks, despite the presence of various analogue filters con-
tained on the e-Health shield as shown in Figure 9. These noises can lead to errors in diagnosis. In this work, a digital Butterworth bandpass filter
is used to suppress the noise (50 Hz). Its transfer function is given by the Equation (1).

1
jGðjωÞj2n ¼ ð1Þ
1 þ ðω=ωc Þ2n

where, n is the order of the filter, ωc represents the cut-off frequency. The filtering result using Butterworth filter is shown in Figure 10.

4.2 | ECG signal to image transformation

Techniques such as Electroencephalogy (EEG), Magnetoencephalogy (MEG), Electrocardiography (ECG), PCG, BCG which produce data in 1-D
form contain important information of the human body but cannot be considered as part of medical imaging directly. Before ECG signal classifica-
tion, different tools have been applied to convert the ECG from 1D to 2D-image (Huang et al., 2019; Kanani & Padole, 2020; Sanivarapu
et al., 2020; Xie et al., 2019) where the author uses the Pan–Tompkins algorithm for 1D-ECG signal to 2D-ECG image conversion. The fact of
transforming ECG signals into scaleograms allows to use a visual computing model to classify the different types of diseases in our data set (see
Figure 8c).
HAMIL ET AL. 9 of 27

4.3 | Cardiac arrhythmia recognition using different models based on automatic feature extraction

Classification of ECG data helps in earlier diagnosis and since the limitation of manual inspection of ECG signals can be overcome by using
computer-aided diagnosis system, different authors have presented their approaches Liu et al. (2020), Ferretti et al. (2020), Subasi and Qaisar (n.
d.) and Qaisar and Subasi (2020b).
In this work, the classification of ECG-scalogram images has been performed using Keras library, which wraps the efficient numerical libraries
Theano and TensorFlow allowing the use of different classical supervised classifiers developed in Scikit-learn.

4.3.1 | ANN model

ANN is a concept of machine learning modelled by the biological brain allowing to map a set of input data onto a set of appropriate outputs using
a known database. Afterward, output results can be produced when the desired output is unknown. According to Bahoura (2014), the mathemati-
cal model which represents the artificial neuron is given by:

X
m
vhj ¼ whj,i xi þ bhj,0 ð2Þ
i¼1

with j ¼ 1,…, N

 
yhj ¼ Φh vhj ð3Þ

where v hj is the answer of the j-th hidden neuron, whj,i is the weight associated with the i-th input layer, xi is the i-th of m input signals, bhj,0 is the
bias of the j-th hidden neuron. yhj represents the output of the j-th of the hidden layer neuron and Φh is the activation function of the j-th hidden
neuron. The output of each neuron k is given by:

X
m
vok ¼ wok,i yhj þ bok,0 ð4Þ
i¼1

with k ¼ 1, …, N

 
yok ¼ Φo v ok ð5Þ

where wok,i is the synaptic weight connecting the output of the j-th hidden layer neuron to the k-th neuron of the output layer, and the bok,0 is the
bias associated with the k-th neuron. yok represents the output of the k-th neuron of the hidden layer.
According to Figure 8d.1 the used model is based on the concatenation of flatten, four dense layers with 200 or 300 neurones with Linear
Rectified Units (ReLU) and softmax function.

4.3.2 | CNN model

Recently, deep learning techniques have been used by many companies namely Apple, Google, Microsoft and NVIDIA (Goodfellow et al., 2016).
CNN has performed well in the biomedical signal and image processing. In this work, it was employed for automated ECG classification using
ECG-sacalogram images. Mainly, CNN consists of four main layers; convolution layers, Rectified Linear Units (ReLu) layers, pooling layers and fully
connected (FC) layers. In the convolution layer, a convolution filter is applied to the input image in which the filter will be sliding over the image
spatially. After the filter slides over the whole image, an activation map will be created by computing the dot product between the image and the
filter at each window location. A convolution layer can have more than one filter. Applying more filters to the image creates a stack of activation
maps that has the cumulative depth equal to the number of filters. Convolution layers are usually followed by ReLu layers, also known as activa-
tion layers. This layer applies ReLu function, which is non-linear operation that induce non-linearity. Pooling layer is a down sampling layer that
operates over each of the activation maps independently to create smaller activation maps spatially. The most two popular approaches are mainly;
Max pooling and Mean pooling. Finally, FC layers perform linear operations on the features extracted by convolution layers and down-sampled by
pooling layers. FC layers which represents the output layer that has the classification percentages which is serving the classification result as a
10 of 27 HAMIL ET AL.

single vector of probabilities these probabilities passed to the softmax classifier to select the class with the highest probability. With the hierarchi-
cal structure of CNNs, features will be evolving over the layers from low-level features to more complex features. CNNs are trained by standard
back propagation algorithms in which the CNN parameters will be adjusted at each training iteration until the error is minimized. GoogleNet, VGG
and AlexNet are some of the available pre-trained CNN models that reported good results. All of these CNN models used ImageNet for training,
which is a large-scale hierarchical labelled dataset. In this study, VGG16 model is used and its architecture is illustrated in Figure 8d.2.

4.3.3 | Using pre-trained CNN weights as feature extractors combined with traditional machine learning

Deep learning techniques can reveal image features, which are not apparent in the original images. Specifically, CNN has been proven extremely
beneficial in feature extraction and learning reason why it is widely adopted by the research community. To compare the performance of ANN
and CNN models with traditional classifiers (SVM, KNN and RF) a transfer learning method is adopted allowing us to benefits from the pre-trained
CNN (already used for the same problem) and combine it with benchmark classifiers where CNN is used as feature extractor. Due to the uncom-
mon availability of a huge medical image dataset, training the entire CNN by medical images to achieve a certain classification accuracy is unlikely
often. Therefore, random initialization of weights is replaced using exist CNN that has been already trained on a large dataset. Transfer learning
can be used in two ways: either through fine-tuning or through using CNN as feature extractor. In fine-tuning, the weights of the pre-trained
CNN model are preserved on some of layers and tuned in the others. Usually, the first layers preserve their weights as the features obtained from
these layers are generic and applicable to other tasks. However, the latter layers provide more specific features that can benefit from fine tuning
approach as they will be adjusted specifically for the targeted dataset. On the other hand, using CNN as feature extractor does not include any
tuning. Using CNN as a feature extractor is based on the idea of accessing the features of any of the layers, and then using those encoded fea-
tures to train another classifier (SVM, KNN and RF).
In this work, VGG16 model is modified to be compatible with the goal of this research (four classes). The first layer (image input) is modified
to be with the size of 224  224  3 and the FC layer modified to 4 outputs. (see Figure 8d.2).
Automatic feature extraction using CNN is usually extracted from the FC layer of any architecture. Fully connected layer extracts only repre-
sentative features that can distinguish between the different classes: NSR, CHF, AF and ARR. In this article, the features are extracted from the
FC layer of VGG16 model.
Furthermore, these features are used to build hybrid systems with another classifier using SVM, KNN and RF classifiers. A brief reminder
about the used classifiers is detailed as follows:
Softmax Classifier:
SoftMax classifier is the most commonly used classifier with CNNs. It takes the raw class scores and normalizes them to sum to one, resulting
in normalized class probabilities. SoftMax uses the cross-entropy loss function in which, basically, the loss looks at the groundtruth class in the
training set and tries to make the corresponding probability of that class as high as possible. Compared to the SVM, SoftMax gives more intuitive
outputs, as it provides probabilities for each class rather than scores.
SVM Classifier:
It is one of the leading and commonly used supervised algorithms in machine learning. The SVM uses training data to create a model that dis-
tinguishes the data entered and predict the new data class. The main objective of the SVM is to find the best hyperplane separating the entire
dataset and optimizing the distance between the nearest data point and the separating hyperplane.
KNN Classifier:
It is a non-parametric machine learning method that is fast, lazy, widely used and instantaneous. In general, KNN’s input vector includes the
feature space and the target that represents the class member that is graded based on the classes of its neighbour’s majority voting technique.
The majority vote is applied to the weights that indicate the distance between each characteristic point and the vector mass centre.
RF Classifier:
It is composed of a large number of collective decision trees that function together. Each distinct tree in this form of classifier spits out a class
prediction, and the class with the most choices to be the prediction of our model. Simplicity and powerfulness are critical impressions behind
random wood.

4.3.4 | Datasets

The used datasets taken from Physiobank are:

• MIT-BIH Arrhythmia Database:

HAMIL ET AL. 11 of 27

This database contains 48 half-hour ECG recordings (two channels), obtained from 47 subjects. The signals are sampled at 360 Hz with 11-bit res-
olution over ±10 mV range.

• MIT-BIH Normal Sinus Rhythm Database:

This database includes 18 long-term ECG recordings of subjects with no significant arrhythmias. The signals are sampled at 128 Hz.

• BIDMC Congestive Heart Failure Database:

This database includes long-term ECG recordings about 20 h in duration. The signals are sampled at 250 Hz with 12-bits resolution over a range
of ±10 mV. The different signals are collected from 15 patients with severe congestive heart failure.

• MIT-BIH AF Database:

The individual recordings are each 10 h in duration. The signals are sampled at 250 Hz with 12-bits resolution over a range of ±10 mV. A set of
23 available records from these 25 records are used.
Models presented in Figure 8 are used in this work allowing non-linear mapping, classifying data and predicting future events with automated
features extraction. Each model operates according to two phases as follows:

Training phase
As shown in Figure 8a 85% of data taken from four physionet datasets have been used during training phase.

Testing phase
Fifteen percent of data taken from the same datasets in addition to ECG collected using e-Health sensors platform have been used during testing phase.

5 | O T H E R B I O S I G N A L S CL A S S I F I C A T I O N

The classification of the remaining five biosignals is achieved by implementing an algorithm based on threshold detection for each corresponding
biosignal and this on the same raspberry pi as illustrated in Figures 11–13 analysing temperature, SPO2, position, GSR and airflow, respectively.

6 | GUI

As shown in Figure 14 the sequence diagram details how the different operations of the proposed system are carried out with the order of the
interaction. The system is starting with the physician who extracts information related to patients from the database after launching a request to

(a) (b)

FIGURE 11 Classification of the temperature (a) and SPO2 (b)

FIGURE 12 Illustration of the different detected positions

12 of 27 HAMIL ET AL.

(a) (b)
RAYMOND
VINCENT PAUL
2022.06.20
14:21:36 +05'30'

FIGURE 13 Classification of GSR (a) and airflow (b)

FIGURE 14 Sequence diagram illustrating the order of the interaction between the different objects

FIGURE 15 Authentication interface

HAMIL ET AL. 13 of 27

the treatment unit to obtain information on the patient’s condition. Launches another request to the acquisition unit, the acquisition unit collects
the measurements and send them to the processing unit and then to the display unit.
An application developed using C # under visual studio (IDE) allows to facilitate the use of the system and the collection of data. It indicates
the different values and the classification result of each biosignal through authentication and state interface (Figures 15 and 16).
The authentication interface allows to save some information relative to each patient such as full name, age, address, phone, … and indication
about his previous health state.
The state interface allows to display all values relative to each biosignal and its classification result.

7 | SECURED WIRELESS D ATA T RA NS MISSI ON

7.1 | XBee modules

The advantages of the XBee technology are: low latency with long battery lifetime, the size of the network which provides more than 65,000
nodes with collision avoidance challenge, and its application in the Direct Sequence Spread Spectrum (DSSS) which makes it a suitable and effi-
cient solution for embedded systems designing. In this work, two XBee Pro S1 modules have been used, operating within ZigBee protocol at a fre-
quency of 2.4 GHz and consuming 60 mW (18 dBm).
The configuration of the XBee modules is made through the X-CTU software Figure 17. Where X-CTU represents a cross-platform applica-
tion from Digi International, which allows developers to interact with Digi (RF) modules through its user graphical interface.

7.2 | Proposed chaos-based encryption

Vital signals passing through wireless communication networks are often subject to numerous threats related to the confidentiality, integrity and privacy of
patients. Therefore, it is wise to consider the security aspect in the design of a patient monitoring system. Conventional cryptosystem such as AES
(Advanced Encryption Signal), DES (Data Encryption Standard) and so on are not suitable for real-time embedded application in terms of speed and power
consumption, many works in the literature have proved that chaos-based cryptosystem is a good candidate for such applications (Azzaz et al., 2019; Azzaz &
Krimil, 2018; Lambi
c et al., 2018). So, the proposed cryptosystem in this work is a stream cipher where the key generator is replaced by a 3D chaotic system
of Lorenz. The architecture of the proposed chaos-based cryptosystem of vital signals carried through six bio-sensors is illustrated in Figure 18.
The Lorenz chaotic system is defined by the model of three dimensional differential equation system given in Equation (6).

FIGURE 16 Biosignals monitoring interface

14 of 27 HAMIL ET AL.

FIGURE 17 X-CTU interface for XBee configuration

FIGURE 18 Proposed architecture of the chaos-based encryption/decryption of vital signals

8
< x_ ¼ σ ðy  xÞ
>
y_ ¼ xz þ ax  y ð6Þ
>
:
z_ ¼ xy  bz
HAMIL ET AL. 15 of 27

Time Evolution of x.
20

10

0
x

-10

-20
0 2 4 6 8 10 12 14 16 18 20
t
Time Evolution of y.
40

20

0
y

-20

-40
0 2 4 6 8 10 12 14 16 18 20
t
Time Evolution of z.
60

50

40
z

30

20

10
0 2 4 6 8 10 12 14 16 18 20
t

FIGURE 19 Evolution of the chaotic signals x, y and z of Lorenz system

Attractor or Lorenz Chaotic Generator

60

55

50

45

40

35
z

30

25

20

15

10
30

20
25
10 20
15
0 10
5
-10 0
-5
-10
-20 -15
y -20
-30 -25 x

FIGURE 20 Three dimensional (3D) chaotic attractor (x  y  z) of Lorenz system

Where the parameters defining the chaotic behaviour of this system are σ ¼ 10, a ¼ 28, b ¼  83 and the initial conditions are x0 ¼ 10, y0 ¼ 10 and
z0 ¼ 10. The chaotic signals of Lorenz system and its three-dimension attractor are shown in Figures 19 and 20, respectively. The key space of the
cryptosystem is composed by the initial conditions, the parameters of the Lorenz chaotic system and the step h ¼ 0:001 of the Euler resolution
method. Each value is codded on 32 bits, which gives 2732 ¼ 2224 combinations. According to Alvarez and Li (2006), the proposed chaos-based
 
cryptosystem is secured against force brute attacks > 2100 .
16 of 27 HAMIL ET AL.

(a)
1

0.5

Amplitude (mV)
0

-0.5
0 0.5 1 1.5 2 2.5
Time (samples) 106
4 (b)
10

2
Amplitude (mV)

-2

0 0.5 1 1.5 2 2.5

Time (samples) 106
(c)
1

0.5
Amplitude (mV)

-0.5
0 0.5 1 1.5 2 2.5
Time (samples) 106

FIGURE 21 Simulation results of the encryption/decryption process using the proposed cryptosystem: (a) original signal, (b) encrypted
signal and (c) decrypted signal

FIGURE 22 Example illustrating the chaos-based encryption/decryption of data acquired from different biosensors
HAMIL ET AL. 17 of 27

(a) (b)

(c)

FIGURE 23 Sinus rhythm with its corresponding time-frequency and histogram representations: (a) original signal, (b) encrypted signal
and (c) decrypted signal

Using the proposed chaos based cryptosystem, Figures 21 and 22 illustrate the encryption/decryption of the ECG signal and all other used
biosignals, respectively.
Figures 23–27 show one signal taken from each recognized class: Normal, AF, CHF and other arrhythmia, respectively with its time-frequency
and histogram representation before (a) and after (b) encryption and decryption (c) processes allowed to properly analyse the different signals and
estimate the efficiency and the robustness of the used method for both data encryption and decryption. Notice the advantage of the optimized
S-Transform (Zidelmal et al., 2017) allowing an accurate access to both time and frequency content of each encrypted and decrypted signals.
The simulation results of the encryption and decryption of the different ECG signals taken from the different classes show that the encrypted
ECG signals are completely buried in the chaotic sequences. Furthermore, the time-frequency representation provided by the Stockwell transform
based on compact support kernel shows that the encrypted signals completely hide the different frequencies relative to the waves constituting
the ECG signal, which are P, QRS and T in the case of absence of cardiac abnormality. As the analysis of the histograms shows that the encrypted
ECG signals are uniformly distributed compared to the original signals (before encryption) and therefore the proposed chaos-based cryptosystem
resists to different statistical attacks. It can also be seen that the reverse process of encryption (decryption) can restore successfully the original
signal.
18 of 27 HAMIL ET AL.

(a) (b)

(c)

FIGURE 24 Atrial fibrillation with its corresponding time-frequency and histogram representations: (a) original signal, (b) encrypted
signal and (c) decrypted signal

8 | EXPERIMENTAL RESULTS

The main advantage of this work is the ability to use it as a principle unit in an IoT system with accessibility to the data and anomalies recognition
from the internet. This allows to reduce the distance between the patient and the physicians. The normalized confusion matrix (Figure 28) summa-
rizes the performance of each model.
The used models predict very well the different classes because all values in the diagonal are very close to 1 with an average accuracy of
97.47, 96.24, 99.56, 99.37 and 97.89% using ANN, CNN-Softmax, CNN-SVM, CNN-KNN and CNN-RF, respectively.

9 | DISCUSSION

To compare the different classifiers, the performance of each model is quantitatively evaluated using four metrics namely, ROC area, F-measure,
Kappa and Accuracy (see Table 1 and Figure 29).
The used metrics are defined as follow:
HAMIL ET AL. 19 of 27

(a) (b)

(c)

FIGURE 25 Congestive heart failure with its corresponding time-frequency and histogram representations: (a) original signal,
(b) encrypted signal and (c) decrypted signal

 
1 TP TN
AUC  ROC ¼ þ ð7Þ
2 TP þ FN TN þ FP

2  TP
F-measure ¼ ð8Þ
2  TPi þ FPi þ FNi

TP þ TN
Accuracy ¼ ð9Þ
TP þ TN þ FP þ FN

Accuracy  Random accuracy

Kappa ¼ ð10Þ
1  Random accuracy

where, Random accuracy ¼ P1  P2 þ ð1  P1 Þð1  P2 Þ with: P1 ¼ TPþFNþTNþFN

TPþFN
, P2 ¼ TPþFNþTNþFN
TPþFP
.
According to Tables 1–3, the proposed models for automatic arrhythmia recognition provide superior results compared to the results
reported in previous studies where the followings can be highlighted:
20 of 27 HAMIL ET AL.

(a) (b) 104 (a)

Amplitude (mV)
(a) 2
600
Amplitude (mV)

500 0

400 -2

300 0 100 200 300 400 500 600 700 800 900 1000
0 100 200 300 400 500 600 700 800 900 1000 Time (samples)
Time (samples) (b)
(b)

Frequency (Hz)
150
Frequency (Hz)

150
100
100
50
50

100 200 300 400 500 600 700 800 900 1000
100 200 300 400 500 600 700 800 900 1000 Time (samples)
Time (samples)
(c)

Observation number
(c) 30
Observation number

100
20

50 10

0 0
250 300 350 400 450 500 550 -4 -3 -2 -1 0 1 2 3 4
ECG-Amplitude ECG-Amplitude 104

(c) (a)
600
Amplitude (mV)

500

400

300
0 100 200 300 400 500 600 700 800 900 1000
Time (sample)
(b)
Frequency (Hz)

150

100

50

100 200 300 400 500 600 700 800 900 1000
Time (samples)
(c)
Observation number

100

50

0
250 300 350 400 450 500 550
ECG-Amplitude

FIGURE 26 Real acquired ECG signal with its corresponding time-frequency and histogram representations: (a) original signal,
(b) encrypted signal and (c) decrypted signal

• The advantage of the presented system is the ability to predict anomaly of each acquired biosignal under a secured transmission based on
chaos algorithm instead of focusing only on the acquisition and transmission of the data without classification nor encryption as proposed by
the majority of authors.
• Classification of ECG signals using ANN, CNN, SVM, KNN and RF followed by a comparison of the results using different metrics (see
Figure 29 and Table 1). Notice that transfer learning approach based feature extraction produced better results than end-to-end training of the
new machine learning.
• The proposed system for vital characteristics monitoring allows to follow-up the state of health in a secure way using an encrypted wireless
transmission. To widen the distance between the acquisition and processing units, it suffices to replace the XBee modules by another technol-
ogy ensuring a wider coverage radius such as 4G and 5G.
• Transmission of data (biosignals) in a secure manner using chaos algorithm (Lorenz).
• The use of an IoT analytic platform service such as ThingsSpeak can allow to visualize and real-time analysis of data streams in the
cloud.
HAMIL ET AL. 21 of 27

(a) (b)
104 (a)
(a)

Amplitude (mV)
220 2
Amplitude (mV)

200
0
180
-2
160
0 100 200 300 400 500 600 700 800 900 1000
0 100 200 300 400 500 600 700 800 900 1000
Time (samples)
Time (samples)
(b)
(b)

Frequency (Hz)
Frequency (Hz)

150
150
100
100
50
50

100 200 300 400 500 600 700 800 900 1000
100 200 300 400 500 600 700 800 900 1000
Time (samples) Time (samples)
(c)

Observation number
(c)
Observation number

30
100
20

50
10

0 0
140 150 160 170 180 190 200 210 220 230 -4 -3 -2 -1 0 1 2 3 4
ECG-Amplitude ECG-Amplitude 104

(c)
(a)
220
Amplitude (mV)

200

180

160

0 100 200 300 400 500 600 700 800 900 1000
Time (samples)
(b)
Frequency (Hz)

150

100

50

100 200 300 400 500 600 700 800 900 1000
Time (samples)
(c)
Observation number

100

50

0
140 150 160 170 180 190 200 210 220 230
ECG-Amplitude

FIGURE 27 Real acquired ECG signal with other arrhythmia under its corresponding time-frequency and histogram representations:
(a) original signal, (b) encrypted signal and (c) decrypted signal

10 | CO NC LUSIO N

Through this work, a new system has been proposed to ensure biosignals monitoring with anomaly recognition. The global approach was
developed for the classification of different vital biosignals transmitted from an e-Health platform. This is in the context of a tool to automate
diagnosis that can even be applied in clinical conditions. Before starting the classification, the acquisition of the different biosignals is neces-
sary to test the execution of the developed system in real-time. For this, the e-Health platform V1.0 has been used with Arduino Uno as an
acquisition unit and Raspberry Pi3 model B+ as a processing unit. Data transfer from the acquisition unit to the processing unit is provided
by a wireless link using Xbee modules. This transmission was successfully secured with a reliable and lightweight chaos-based cryptosystem.
The data are decrypted by the reverse operation in the processing unit. For the ECG signal, digital filtering was performed in order to reduce
the noise affecting the signal. Then automatic recognition of arrhythmia by the development and implementation of different machine learning
algorithms (ANN, CNN, SVM, KNN and RF) is successfully validated after the conversion of one-dimensional (1D) ECG signals to 2D images
using the scalogram representation. The used architectures based on AI allowed to reach an average accuracy of 97.47, 96.24, 99.56 99.37
and 97.89% related to the recognition of NSR,CHF, AF and ARR using ANN, CNN, SVM, KNN and RF, respectively. Simulation and experi-
mental results show that the proposed method can be considered as an efficient tool for the classification of multiple biosignals. Furthermore,
once the used models are well-trained, they can be exploited to assist cardiologists by providing quick and reliable second opinions on the
22 of 27 HAMIL ET AL.

FIGURE 28 The normalized confusion matrix: (a) using ANN model, (b) using CNN-softmax, (c) using CNN-SVM, (d) using CNN-KNN,
(e) using CNN-RF

TABLE 1 Performance evaluation of different machine learning methods

ANN CNN-Softmax

ROC area F-measure Kappa Accuracy % ROC area F-measure Kappa Accuracy %
NSR 0.969 0.951 0.935 97.66 0.956 0.942 0.924 97.21
AF 0.947 0.925 0.899 96.27 0.930 0.893 0.854 94.47
CHF 0.949 0.926 0.913 96.71 0.970 0.960 0.948 98.11
ARR 0.986 0.984 0.978 99.26 0.948 0.901 0.867 95.19
Average 0.963 0.946 0.931 97.47 0.948 0.924 0.898 96.24

CNN-SVM CNN-KNN CNN-RF

ROC Accuracy ROC Accuracy ROC Accuracy

area F-measure Kappa % area F-measure Kappa % area F-measure Kappa %
NSR 0.985 0.985 0.978 99.25 0.985 0.984 0.973 99.25 0.970 0.960 0.946 98.05
AF 1 1 1 100 0.995 0.990 0.986 99.5 0.960 0.948 0.933 97.40
CHF 0.994 0.994 0.991 99.75 0.985 0.980 0.973 99.00 0.970 0.938 0.916 96.86
ARR 0.993 0.980 0.973 99.00 0.995 0.994 0.992 99.75 0.980 0.985 0.978 99.27
Average 0.993 0.989 0.985 99.56 0.990 0.987 0.981 99.37 0.970 0.957 0.943 97.89

diagnosis. To facilitate the use of the system in clinical conditions, an application developed in C# with a dedicated graphical interface dis-
playing different vital characteristics as well as the classification result of each biosignal transmitted in real-time from the processing unit via
WiFi link. As future work, the following points are to be considered:
 HAMIL ET AL.

TABLE 2 Comparison between the achieved results related to automatic arrhythmia recognition with those reported in the literature

Method Dataset Feature set Classifier Number of classes Performance reported (%)
Qaisar and Subasi (2020a) MIT-BIH arrhythmia Autoregressive (AR) Burg SVM, k-NN, ANN, Random 5 best ACC = 94.07
forest and Rotation forest
Alickovic and Subasi (2016) MIT-BIH database and St DWT Random Forest 5 99.33
O. Yildirim et al. (2019) MIT-BIH arrhythmia convolutional auto-encoder (CAE) LSTM 5 Acc = 99. 11
Martis et al. (2012) MIT-BIH arrhythmia PCA LS SVM 5 Acc = 98.11
W. Yang, Si, et al. (2018) MIT-BIHarrhythmia PCANet Linear SVM 5 Acc = 97.08
Kiranyaz et al. (2015) MIT-BIH arrhythmia Raw data CNN 5 Acc = 99
Yang, Bai, et al. (2018) MIT-BIH arrhythmia SSAEs Softmax 6 Acc = 99.5
Oh et al. (2018) MIT-BIT arrhythmia Raw data CNN + LSTM 5 Acc = 98.1
Ö. Yildirim (2018) MIT-BIH arrhythmia DWT sub bands BLSTM 5 Acc = 99.39
Hammad et al. (2020) MIT-BIT arrhythmia Deep learning model + GA KNN 5 Acc = 98.00, SEN = 99.70
Qaisar and Subasi (2020a) MIT-BIT arrhythmia ARFIR SLI + AR Burg Rotation Forest - Acc = 94.07
Alickovic and Subasi (2016) MIT-BIH database and St DWT RF Acc = 99.95/99.8
Alickovic and Subasi (2015) MIT-BIH arrhythmia AR modelling SVM, KNN, MLP 5 Acc = 99.93
Present Work MIT-BIH Arrhythmia, Scalogram ANN 4 97.47
MIT-BIH NSR,
BIDMC CHF,
MIT-BIH AF, Real ECG
// Scalogram CNN 4 96.24
// Scalogram SVM 4 99.56
// Scalogram KNN 4 99.37
// Scalogram RF 4 97.89
23 of 27
24 of 27 HAMIL ET AL.

TABLE 3 Comparison with other proposed systems based smart wearables

Transmission Data encryption/

Work System Biosignals Classification technology decryption
Lin et al. (2006) eHealth monitoring 3 N/A Network NRZ
Kumar Secure health monitoring 2 N/A N/A PingPong-128 st. cipher,
et al. (2010) PingPong-MAC
Y.-M. Huang Telecardiology sensor 1 N/A N/A Cipher cryptography
et al. (2009) network
Malasri and Secure wireless medical 1 N/A N/A Symmetric encry/
Wang (2009) sensor network decryption
Shahidul Islam IOT 3 N/A Bluetooth N/A
et al. (2019) + LoRa
Randazzo Wearable Smart Device 4 N/A GSM N/A
et al. (2020) (mHealth)
R
akay eHealth 4 N/A XBee N/A
et al. (2015)
Proposed Secured Telehealth 6 Threshold detection, K-NN, SVM, XBee + WiFi Chaos (Lorenz)
RF, ANN and CNN

1
0.98
0.96
0.94
0.92
0.9
0.88
0.86
0.84
0.82
0.8
ANN CNN CNN-SVM CNN-KNN CNN-RF
ROC area F-measure Kappa Accuracy

FIGURE 29 Performance metrics of each classifier

• The use of some optimized time-frequency distributions (adopting compact support kernels) for ECG signal to image transformation can
improve more the accuracy of classification.
• The use of Graphics Processing Unit (GPU) to reduce the complexity and power consumption due to computation.
• In parallel, the Classification of PCG signals can be explored with the presented technique.
• Also the ability to exploit the capacity of the network by sharing the result of the diagnostic using a server machine allowing to construct an
intelligent and secure IoT system by exploiting different technologies 4G, 5G and others.

Finally, the use of field programmable gate array (FPGA) as a material accelerator unit is suitable solution for the proposed system to get the
best performances in terms of real-time, flexibility and rapidity.

CONF LICT OF IN TE RE ST
The authors declare that they have no conflict of interest.

DATA AVAI LAB ILITY S TATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.

ORCID
Mohamed Salah Azzaz https://orcid.org/0000-0001-6207-7626
HAMIL ET AL. 25 of 27

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AUTHOR BIOGRAPHI ES

Hocine Hamil received the M.Sc. degree in Electrical Engineering and Computer Science from University Mouloud Mammeri of Tizi-Ouzou,
Algeria. Currently he is working towards his Ph.D. degree in collaboration with Military Polytechnics School of Algiers (EMP) and IRIMAS Insti-
tute, University of Haute-Alsace, French. His current research interests include digital signal processing, time-frequency analysis, embedded
system design, artificial intelligence and FPGA real-time implementation of algorithms applied for biomedical engineering and communication.

Zahia Zidelmal received the M.Sc. degree in signal processing and biomedical engineering in 1996 from University Mouloud Mammeri of Tizi-
Ouzou, Algeria. She received the Ph.D degree in 2012 She is currently Associate Professor at University Mouloud Mammeri of Tizi-Ouzou,
Algeria. Her research interests are statistical signal processing with applications in biomedical and communications, time-frequency represen-
tations and pattern recognition with Support Vector Machines (SVMs).

Mohamed Salah Azzaz received the Ph.D degree in electronics from Polytechnic Military School of Algiers (EMP), Algeria in collaboration with
Lorraine University of Metz, in 2012. Currently, he is the head of the Electronic and Digital Systems Laboratory. His research interests include:
design and implementation of real-time signal processing architectures, FPGA design, system-on-chip development, chaos-based encryption,
chaos-based watermarking, Biometry and hardware/software co-design. He has authored and co-authored more than 50 publications.
HAMIL ET AL. 27 of 27

Samir Sakhi received the Engineering and Magister degrees in Automatic from the Polytechnic Military School of Alger (EMP). In 2014, he
received his Ph.D. in Automatic from the same school. Since 2014, he holds a teaching and research positions at the department of Automatic,
EMP. His research interests are in embedded systems, Processors, FPGA, SoC, RTOS, design, co-design and implementation.

Redouane Kaibou received his engineering degree in Telecommunications from Military Polytechnics School of Algiers (EMP) in 2007. He
received the degree of Master by research in Avionic Systems Design from Cranfield University, UK in 2012. He is currently pursuing PhD in
EMP. His research interests include hardware/software FPGA co-design, chaos based encryption and watermarking, real-time image
processing applications.

Salem Djilali received engineering and Master degrees in Telecommunications at Military Polytechnic School of Algiers (EMP). His research
interest embedded systems and signal processing.

Djaffar Ould Abdeslam received the Ph.D. degree from the University of Haute-Alsace, Mulhouse, France, in 2005. From 2007, he is an Asso-
ciate Professor at the University of Haute-Alsace. He received the Habilitation in Electrical Engineering from the University of Haute-Alsace
in 2014. His research interest includes Artificial Neural Networks applied to Power Systems, Signal Processing for Power Quality Improve-
ment, Smart Metering, Smart Building and Smart Grids.

How to cite this article: Hamil, H., Zidelmal, Z., Azzaz, M. S., Sakhi, S., Kaibou, R., Djilali, S., & Ould Abdeslam, D. (2021). Design of a
secured telehealth system based on multiple biosignals diagnosis and classification for IoT application. Expert Systems, e12765. https://doi.
org/10.1111/exsy.12765