Content uploaded by Siqabukile Ndlovu
Author content
All content in this area was uploaded by Siqabukile Ndlovu on Apr 28, 2020
Content may be subject to copyright.
Proceedings of Informing Science & IT Education Conference (InSITE) 2015
Cite as: Dube, S., Ndlovu, S., Nyathi, T., & Sibanda, K. (2015). QR code based patient medical health records trans-
mission: Zimbabwean case. Proceedings of Informing Science & IT Education Conference (InSITE) 2015, 521-520.
Retrieved from http://Proceedings.InformingScience.org/InSITE2015/InSITE15p521-530Dube1523.pdf
Editor: Eli Cohen
QR Code Based Patient Medical Health Records
Transmission: Zimbabwean Case
Sibusisiwe Dube, Siqabukile Ndlovu, Thambo Nyathi,
and Khulekani Sibanda
National University of Science and Technology,
Bulawayo, Bulawayo Province, Zimbabwe
sibusisiwe.dube@nust.ac.zw, siqabukile.sihwa@nust.ac.zw,
thambo.nyathi@nust.ac.zw, khulekani.sibanda@nust.ac.zw
Abstract
In Zimbabwe the health care delivery system is hierarchical and patient transfer from the lower
level to the next higher level health care facility involves patients carrying their physical medical
record card. A medical record card holds information pertaining to the patient’s medical history,
pre-existing allergies, medical health conditions, prescribed medication the patient is currently
taking among other details. Recording such patient information on a medical health card renders
it susceptible to tempering, loss, and misinterpretation as well as susceptible to breaches in confi-
dentiality. In this paper, we propose the application of Quick Response (QR) codes to secure and
transmit this sensitive patient information from one level of the health care delivery system to
another. Other security methods such as steganography could be used, but in this paper we pro-
pose the use of QR codes owing to the high proliferation of mobile phones in the country, high
storage capacity, flexibility, ease of use and their capability to maintain data integrity as well as
storage of data in any format.
Keywords QR code(s), medical health records, mobile phone, patient, medical health card
Introduction
The health care delivery system in Zimbabwe has a hierarchical structure depicted in
Figure 1.
In an ideal situation the community, this could be a village in a rural setting or a locale in an ur-
ban setting is manned by an individual with basic medical training referred to as a community
health worker (CHW)(Ministry of Health &Child Welfare Zimbabwe, 2013). The CHW is not
usually attached to any physical structure such as a clinic but is mobile within the community
he/she can make home visits and be vis-
ited to attend to minor ailments. This
scenario is no longer the case in urban
settings as people are not restricted in
choice when it comes to health issues,
but is still more prevalent in rural areas
which house the majority of the Zimba-
bwean populace. If a patient who is at-
tended to by the CHW requires further
treatment the CHW verbally refers them
to the community health clinic/facility
Material published as part of this publication, either on-line or
in print, is copyrighted by the Informing Science Institute.
Permission to make digital or paper copy of part or all of these
works for personal or classroom use is granted without fee
provided that the copies are not made or distributed for profit
or commercial advantage AND that copies 1) bear this notice
in full and 2) give the full citation on the first page. It is per-
missible to abstract these works so long as credit is given. To
copy in all other cases or to republish or to post on a server or
to redistribute to lists requires specific permission and payment
of a fee. Contact Publisher@InformingScience.org to request
redistribution permission.
QR Code Based Patient Medical Health Records Transmission
522
(CHF). The CHF is manned by nurses and has a periodical visiting doctor although the ideal situ-
ation will be to a have one stationed there permanently. In both instances i.e. successful treatment
or referral there is currently no record kept by the CHW. This is an inconvenience as the patient
will have to re-narrate their health problem when they are referred to the clinic. At the CHF, the
nurse will perform the standard basic medical examination procedures which may include but are
not limited to checking the weight, blood pressure and temperature of the patient. These details,
together with the narrated health problem are recorded in a medical record card. At this point of
the hierarchy the nurse repeats this process for every new patient. The nurse, at the CHF, has the
authority to diagnose and treat except if the problem is major and requires the attention of a visit-
ing doctor. Upon successful diagnosis, the patient either gets free medication or gets a prescrip-
tion to purchase the medication and returns home without giving feed back to the CHW. If diag-
nosis and/or treatment are not successful the patient is further transferred to a referral district hos-
pital (DH) which is at the next level in the hierarchy.
Figure. 1 Structure of the Health System
(Ministry of Health and Child Welfare Zimbabwe, 2013)
On referral, the patient maintains the same medical record card with the details of their history,
diagnosis, condition and comments from either the clinic nurse or the clinic visiting doctor. The
same medical record card is maintained possibly to the highest level in the hierarchy indicating
what was observed and prescribed all the way from the clinic to the referral hospital where the
patiently is possibly treated successfully. It is maintained throughout the monitoring and review
process downward from the referral hospital to the clinic as indicated in Figure 2.
Dube, Ndlovu, Nyathi & Sibanda
523
CHF
DISCHARGED
DISTRICT HF
YES
NO FURTHER
TREATMENT
FURTHER
TREATMENT
FURTHER
TREATMENT
YES
YES
NO
NO
NO
REFERRALS
FROM THE DHW
PROVINCIAL
HF
REFERRAL
NATIONAL
HF
FURTHER
TREATMENT
YES
Figure 2 Patient Movement within Hierarchy
Problem Statement
During the process of patient transfer the patient's medical information is vulnerable and suscep-
tible to various degrees of integrity compromise. For example the medical record card may get
lost hence losing all the important patient medical information. It is also susceptible to infor-
mation tempering either by the patient or other third parties. For example, the medical record card
can be scribbled on, soiled, illegally altered or torn. An additional problem is that the medical
record card may be accessible to unauthorised individuals who may eavesdrop the information on
the card and maliciously release it hence violating the privacy of the patient. Most importantly,
despite access by unintended recipients, the details on the medical record card are also prone to
misinterpretation owing to illegible handwriting. All these problems may result in a breached se-
curity based on the lack of confidentiality, integrity and availability of the authentic patient medi-
cal information. The research thus seeks to find an answer to the question as to how the use of QR
codes can enable secure delivery of patient medical information.
Aim and Objectives
The aim of the paper is to evaluate the capability of the QR code to secure patient medical infor-
mation during transit maintaining confidentiality, integrity and availability at the intended desti-
nation within the hierarchical structure of the health delivery system in Zimbabwe. We also advo-
cate a secure and affordable information transmission method that ensures the delivery of com-
plete, accurate and well documented patient medical records.
QR Code Based Patient Medical Health Records Transmission
524
Related Work
Method for Privacy-Protecting Display and Exchange of
Emergency Information on Mobile Devices
Salvador and Christian (2012) developed a solution that allows users to decode patient infor-
mation and automatically notify authorized contacts of the nature of the emergency and the loca-
tion where the patient is being cared for. A QR code is created by encoding the mobile phone us-
er’s emergency and medical information (such as the name and contact details of the user’s next
of kin, their doctor or specialist, blood group, allergies, etc.). The created code image is then used
as a wallpaper on the phone. This allows anyone to scan the code without unlocking the phone.
Scanning and decoding the QR code can be accomplished with any standard QR Code reader, but
when read with QRCScan, additional information is retrieved and revealed. This helps emergency
medical responders by enabling them to provide medical care with a more informed base.
QR Codes Could Minimize Medical Errors Made by First
Responders
Drug mistakes are the most common recorded errors in the healthcare industry all over the world
(Dong-Hee, Jaemin, & Byeng-Hee, 2012). According to the same authors, medication er-
rors affect more than 1.5 million people in US each year which translates to $3.5 billion spent on
related treatments. QR codes could minimise the chances of these errors by offering accurate in-
formation to first responders who can easily read this information by using a QR code scanner on
their Smartphones. In this research, QR codes holding the patient’s information are tattooed onto
an area easily reachable by first responders. The information would also provide accountability
when a treatment does not go the way it was planned. Many of these medical errors are preventa-
ble through an increase in communication between healthcare providers, improved patient identi-
fication, and consumer knowledge (Dong-Hee, Jaemin, & Byeng-Hee, 2012).
A Novel Secret sharing technique using QR Code
In this paper, (Jun-Chou, Yu-Chen, & Hsien-Ju, 2013) propose a secret sharing mechanism to
enhance the security and data privacy for QR codes. The secret sharing scheme was first proposed
by Shamir in 1979 (Shamir, 1979). The main idea of the secret sharing scheme divides a secret
into n shadows or called shares. Anyone cannot decrypt the original secret from their own share.
The secret can be recovered only when any of t out of n shadows (t<=n) are held together. The
proposed technique improves data security during data transmission. On the other hand, the pro-
posed technique does not need to establish a back-end database beforehand for contents search-
ing. It direct embeds the secret data into tags therefore the proposed technique can save a lot of
hardware cost and software maintenance. The proposed technique can be applied to some applica-
tions such as electronic tickets, airline luggage inspection, medical e-health system, and other
fields. However, the major drawback is that the recovery process requires all the stakeholders to
come together which may not always be possible in the Zimbabwean rural setting. This would
also affect the speed of getting the information and would mean the patient would have to wait
for their information to be decoded.
Proposed Solution
QR codes can be implemented to solve the problems stated in the problem statement section of
this paper. QR codes are 2 dimensional barcodes which provide instant access to information
(Espejel-Trujillo, Castillo-Camacho, Nakano-Miyatake, & Perez-Meana, 2012), (Gao & Prakash,
2007). They allow for storage of higher amounts of data compared to conventional barcodes
Dube, Ndlovu, Nyathi & Sibanda
525
which is appropriate for the proposed solution. This data can be in the form of numbers (maxi-
mum 7,089 characters), text (maximum 4,296 characters), binary (maximum 2,953 bytes) or kanji
characters (maximum 1,817 characters) and this would allow even pictures to be sent. An inter-
esting feature of QR codes is their capability to perform error correction in case the parts of the
code are damaged (Espejel-Trujillo, Castillo-Camacho, Nakano-Miyatake, & Perez-Meana,
2012). This means even if the code is damaged, the information in it will still be valid and usable.
They can be coded and decoded on smartphones through the in-built cameras as long as the
smartphone is equipped with a QR code reader.
QR code readers can be downloaded for free from the internet which another advantage of the
proposed solution is given that Zimbabwe is a developing country. QR codes can handle infor-
mation in a variety of formats such as URLs, contact information, SMS and plain text among oth-
ers (Law & So, 2010). As research has shown, QR codes have proved to be useful in several
fields. In the medical field, they have been used on food and drink packages to show the nutri-
tional information these products carry (Yeh, You, & Jong, 2008), as assistive tools for emergen-
cy workers and as transaction authentication tools for medical billing (Starnberger, Froihofer, &
Goeschka, 2009.). QR codes have been and can be tattooed onto patients (Dong-Hee, Jaemin, &
Byeng-Hee, 2012) and this helps particularly in situations where patients are in a serious condi-
tion.
The tattooed information can still be decoded as and when needed as it has a direct link with the
specific patient’s medical health records. Patients can also decode QR coded instructions on how
their medication should be administered. However due to cultural constraints, this paper recom-
mends that the patient medical health information, prescriptions and the instructions for the medi-
cine administration be restricted to the QR codes encoded and decoded via the smartphones and
not tattooed. This means at the source, the patient medical health details are encoded and at the
destination decoded using a smartphone.
Methodology
The research approach followed is the Action Research methodology. In Action Research the re-
searcher tries to provide a service to a research "client", often an entity, and at the same time add
to the body of knowledge in a particular domain (Nyathi, Dube, Sibanda, & Mutunhu, 2013). For
example, in a technology-related domain, an Action Research study could involve the researcher
introducing a new technology, and at the same time studying the effects of the technology in that
entity. The methodology best suits the problem at hand as it involves the participation of the sub-
jects in the provision of a solution to the security problem. Action research is used in real life sit-
uations, rather than in artificial, experimental studies, as its primary focus is on solving real life
problems. It can be used by social scientists for preliminary or pilot research. It is mostly used
when the situation is too ambiguous to come up with a precise research question. Mostly it is cho-
sen when circumstances require flexibility, the participation of the people in the research, or when
change must take place quickly or fully. Figure 3 depicts the phases in an Action Research meth-
odology.
Stage 1: Diagnosis
The diagnosis stage involves the identification of an enhancement opportunity or a general prob-
lem to be solved at the client entity. An enhancement opportunity has been identified in the trans-
fer of patient information from one level to the other. Since patient information is transmitted on
a medical record card it is prone to loss, misinterpretation, eavesdropping and unauthorized edit-
ing hence the need for a more secure method of transmission capable of countering such identi-
fied problems. QR codes can be used to securely transmit confidential patient information. Data
transmission using QR codes is reliable as they can still be read even when they are damaged.
QR Code Based Patient Medical Health Records Transmission
526
Figure 3: Stages of Action Research Methodology
Stage 2: Action Planning
Action planning involves considering the alternative solutions to attain the enhancement or solve
the identified problem(s). The possible solutions include the design, development and: implemen-
tation of a centralized database to store patient information; which can be transmitted via the e-
mail, which can further be secured by steganography. However there is a challenge of infrastruc-
ture particularly in the lower levels of the hierarchy of the health delivery system. These areas do
not have electrical power to ensure the use of computing technology. This renders this alternative
not feasible. The other alternative is the use of an Android app (Reiser & Bruce, 2008.) to transfer
information between stations. This alternative is also not feasible given that the available apps are
not customized for the given situation. The use of QR codes as both the storage and transmission
method of medical records is the most feasibly solution to the problem. This is a multipurpose
method which comes in handy in the given economic environment as information can be record-
ed, stored, transmitted and retrieved using a single device.
Stage 3: Action Taking
In the action taking stage the best course of action among those considered in the previous stage
is selected and implemented. The alternative selected to implement a solution to the problem is
the use of QR codes. There are a number of reasons why this option was selected. The QR code
technology is easy to deploy, fast and economical. QR codes allow their contents to be decoded at
high speed (Espejel-Trujillo, Castillo-Camacho, Nakano-Miyatake, & Perez-Meana, 2012),
(Rouillard, 2008). They carry information in two directions i.e. vertically and horizontally, hence
they are capable of handling large amounts of data. QR codes can be combined into one large
symbol. One symbol can then be divided into 16 separate symbols making the data capacity ex-
tremely large. The other alternatives considered in the Action Planning phase were not selected
because of the following disadvantages: performance degradation as the size of the database in-
creases, issues of scalability since data for the whole nation has to be centrally stored, inaccessi-
bility when offline, security vulnerabilities, dependence on electrical power, resource intensive as
each point will have to be equipped with at least the basic computing infrastructure which in-
cludes hardware, software network connection and communication devices and all these have a
high initial and maintenance costs.
Dube, Ndlovu, Nyathi & Sibanda
527
On the other hand the use of QR codes is more feasible due to accessibility to low cost
smartphones and the freely available QR code application which can be downloaded from the
internet at no cost except the insignificant internet connectivity cost. The implementation of the
proposed system will entail a patient visiting a low level health care institution were a caregiver
diagnoses and treats them. The diagnosis and treatment are recorded on a medical record card that
should be safely kept at this health facility for future reference instead of the patient carrying it
around. If treatment fails at that level, the caregiver generates a QR code from the recorded in-
formation and encrypts it before sending it to the next higher level health care facility. When the
patient is referred, they will only need to carry their national identity card so that their data can be
retrieved.
QRDroid is an Android application used to generate and decode QR codes. It is freely available
for downloading on the internet. The application has two modules: a code generator and a code
reader (Kheder & Alvi, 2013). The QR code generator module is used to generate the QR code
where the user selects the “Plain Text” option on the type of QR code to generate and then types
the medical information of the patient in the console. Before sending, the created code is encrypt-
ed for extra security. The benefit of this application is that it allows for the generation of QR
codes using any other type of information like pictures. This allows x-rays, scans and the actual
image of the patient’s initial health status when they first visited the lower health care facility to
be encoded and transmitted for further examination. The generated QR code can then be sent to
the next higher level health care institution were the patient has been referred to as an MMS or
any communications application that can send and receive any type of information like Whatsapp.
At the receiving end the code is scanned using the reading module and the decryption key is en-
tered to decode information.
Stage 4: Evaluating
This stage involves the study of the outcomes of the selected course of action. Using QR codes
has proved to be a very secure and affordable method of patient medical health information
transmission. The information is delivered to the intended destination in its expected and intended
form. The patient information integrity and confidentiality are maintained and this information is
available as and when required. It neither disappears, leaks nor allows modification while on
transit. It also retains its integrity as it does not suffer from misinterpretation caused by illegible
handwriting. As long as the information is sent to the intended recipient, QR codes offer confi-
dentiality of patient information.
Stage 5: Specifying Learning
The specifying learning stage reviews the outcomes of the evaluating stage and builds knowledge
in the form of a model describing the situation under study. The major challenge faced in Zimba-
bwe is a lack of a centralized system that keeps medical information of all patients who visit pub-
lic hospitals. The system we have proposed helps when it comes to transferring patient infor-
mation from one level to another level in the health care delivery system but it was going to be of
more help if that information was stored centrally and any changes in a patient’s health card to
reflect in the central system.
Discussion and Conclusion
QR codes are a very reliable means of transmitting patient information within the health care de-
livery system hierarchy. The QR codes ensure confidentiality, integrity and availability of the
transmitted patient information from one level of the health delivery system hierarchy to the oth-
er. This is essential for preventing high mortality rates possibly caused by wrong diagnosis and
treatment as a result of lost or misinterpreted records. Figure 4 is an extract of an actual child
QR Code Based Patient Medical Health Records Transmission
528
health card used in Zimbabwe showing the type information that is recorded in it. Looking at the
figure immediately brings out the issue of illegible handwriting.
Figure 4: An extract of a QR coded baby health card.
Figure 5 is a QR code produced from the information recorded in the child health card in Figure
3. This QR code can then be encrypted using the encryption function found in QRDroid and
passed on to another health centre or doctor in case of referral. This is proof that the use of QR
codes is a highly secure, reliable and trustworthy method to transfer sensitive data.
Figure 5: QR code containing information on the baby health card
System deployment expense, user education and IT literacy are parameters perceived to hamper
the adoption process. However as already indicated the critical infrastructure for system adoption
already exists and Zimbabwe enjoys the highest literacy rate in Africa of 91% which is likely to
make IT literacy conversion seamless.
Dube, Ndlovu, Nyathi & Sibanda
529
References
Dong-Hee, S., Jaemin, J., & Byeng-Hee, C. (2012). The psychology behind QR codes: User experience
perspective. Computers in Human Behavior 28 , 1417–1426.
Espejel-Trujillo, A., Castillo-Camacho, I., Nakano-Miyatake, M., & Perez-Meana, H. (2012). Identity
Document Authentication Based on VSS and QR Codes. Procedia Technology 3, 241 – 250.
Gao, J., & Prakash, L. J. (2007). Understanding 2D-barcode technology and applications in m-commerce –
design and implementation of a 2D barcode processing solution”. Proceedings of the Computer
Software and Applications Conference,. Bejing,.
Jun-Chou, C., Yu-Chen, H., & Hsien-Ju, K. (2013). A Novel Secret Sharing Technique Using QR Code.
International Journal of Image Processing (IJIP), Volume (4) : Issue (5).
Kheder, L. S., & Alvi, A. (2013). Authentication System Using Quick Response Code. International
Journal of Management, IT and Engineering, Vol 3, Issue 2, 373-38.
Law, C., & So, S. (2010). , QR codes in education. Journal of Educational Technology. Development and
Exchange, 3(1),, 85-100.
Ministry of Health and Child Welfare Zimbabwe, A. (2013, October 20). Hierarchical structure of the
health delivery system. Retrieved from mohcc.gov.zw: http://www.mohcc.gov.zw/
Nyathi, T., Dube, S., Sibanda, K., & Mutunhu, B. (2013). Poultry Contractual Farming Decision Support
System. IST Africa 2013 Proceedings (pp. 1-8). Kenya: IST Africa.
Reiser, S., & Bruce, R. (2008.). Service learning meets mobile computing. Proceedings of the Annual
Southeast Regional Conference. Auburn, Alabama.
Rouillard, J. (2008). Contextual QR codes. Proceedings of the 3rd International Multi-Conference on
Computing in the Global Information Technology, . Athens, Greece.
Salvador, A., & Christian, P. (2012). Method for Privacy-Protecting Display and Exchange of Emergency
Information on Mobile Devices.
Shamir, A. (1979). “How to Share a Secret. Communication of the ACM, 22(11), 612-613.
Starnberger, G., Froihofer, L., & Goeschka, K. ( 2009.). QR-TAN: Secure mobile transaction
authentication. Proceedings of the Availability, Reliability and Security, . Fukuoka, Japan.
Yeh, Y., You, J., & Jong, G. (2008). The 2D bar-code technology applications in medical information
management. Proceedings of the Intelligent Systems Design and Applications. Kaohsiung, Taiwan,.
Biographies
Sibusisiwe Dube is a PhD in Information Systems student at the Uni-
versity of Cape Town, South Africa. She has worked as a Lecturer and
her research interest is on technology enabled education. The research
work is available in the IEEE sponsored conference proceedings such
as IST as well as other conference proceedings such as the e-skills,
ECEL, ICAT and SACLA. Mrs Dube holds an MSc in Computer Sci-
ence, and BSc in Information Systems.
QR Code Based Patient Medical Health Records Transmission
530
Siqabukile Ndlovu is a Computer Science Maters’ graduate who has
been teaching at the National University of Science and Technology
(Zimbabwe) for the past five years. Her publishing career started in
2013 and to date, she has collaboratively published two articles with
international journals (“Beacon Frame Manipulation to Mitigate Rogue
Access Points: Case of Smartphone Rogue Access Points.”: Interna-
tional Journal of Advanced Computer Technology (COMPUSOFT).
02/2014; Three(Two):576 and “Optimisation of the Linear Probability
Model for Credit Risk Management.”: International Journal of Com-
puter and Information Technology (ISSN: 2279 – 0764) Volume 03 –
Issue 06, November 2014 ) with another article awaiting publishing in
the near future. Siqabukile has also presented a conference paper entitled “Wireless Security” at
the ICT for Africa 2013 Conference held in Harare—Zimbabwe in February 2013. She is regis-
tered as a Technovation mentor to teach and motivate young
Thambo Nyathi is currently working towards his PhD with the Uni-
versity of Kwazulu Natal in South Africa. He holds a MSc in Comput-
er Science and is an avid researcher interested in, Computer security,
application of bio inspired techniques in cybersecurity.
Khulekani Sibanda is a Lecturer in the department of computer sci-
ence at the National University of science and technology. He holds a
Master’s Degree in Computer Science. His research interests lie in the
fields of security, networking and business intelligence. Mr Sibanda’s
research has been published in IEEE sponsored conferences such as the
IST Africa
