Additional Topics to Consider

When considering biometrics for identity management in healthcare and public health programs, it is also important to consider advantages and limitations. These can be grouped under the following topics:

Accuracy & Efficiency

As described previously in the Role in Identity Management section, biometrics can be incorporated into identity management to help patient identification. Biometrics can assist with the matching process, record keeping, and continuity of care. For example, The application of a biometric identification technique for linking community and hospital data in rural Ghana details the effect of biometric implementation in rural Ghana.22

Looking to make patient identification and record matching more efficient, Nigeria, Côte d’Ivoire, Haiti, and Ethiopia’s eCHIS implemented unimodal biometric systems with fingerprint biometrics. 13,14,15,16

While this incorporation helps to streamline processes, the following findings could impact accuracy and/or efficiency

• Connectivity: When facilities are offline, they are not able to access national databases, therefore, the patient information is searched for and stored locally. This could result in a lag time in updating records. In Haiti, local search and storage of information is available if connectivity issues are encountered and this information will be transmitted once connection is restored. 15 In Ethiopia’s eCHIS health workers work with patients in rural areas sometime face connectivity issues. Sim SIM Cards are available in the tablets used, which allow for the syncing of information to the central server that is located at the Ministry of Health. Offline capability is available in areas of low connectivity, such as in rural areas, offline capability. And therefore, syncing this information was discussed in the workflows.16

• Data Output: The generation of data may contain errors. For example, after implementation, Côte d’Ivoire encountered false positives and false negatives. Upon reviewing, hidden code errors were found. As a result, they decided to adjust fingerprint capture and matching thresholds; and to test and continuously review outputs.14

• Biometric Capture: Capturing biometric characteristic data may be impacted due to a patient not having that characteristic, a patient not consenting to biometrics, and/or issues in the capturing process. For example, if a patient does not consent or data is not able to be collected on the biometric characteristic, adding redundancy to the system, or utilizing previous processes could help. For example, Simprints suggests having a multimodal biometric system and Côte d’Ivoire plans to utilize their previous process focused on collecting demographic information.14

Issues can also occur in the capturing processes if processes are not clear. Having trainings, creating reference materials such as workflows and standard operating procedures (SOPs) as discussed by Côte d’Ivoire and Haiti and can help further with accuracy and efficiency.14,15 Ethiopia’s eCHIS utilizes fingerprint biometric technology that returns a few potential matches once a fingerprint is captured for the healthcare worker to review and verify patient information.16

Privacy & Security

As described previously in the Overview, Role in Identity Management, and Choosing Biometric Characteristics and Modalities sections, there are various biometric characteristics and modalities available to consider for implementation; unimodal and multimodal biometric systems; and standards and guidelines. In An Artificial Neural Network Framework for Gait Based Biometrics, security risks such as include brute force attacks, dictionary attacks, attaching device, impersonation attacks, freshness, and efficiency are discussed.23

Studies and reviews have looked at the various modality classifications and have suggested that various layers and components can provide more security from attacks.17,24,25,26 Because of the variety of implementation techniques, suggestions, and software available, it will be helpful to research the various options when planning for biometrics implementation.

Côte d’Ivoire shared general background information on the use of fingerprints as a biometric characteristics and fingerprint template files. When fingerprint template files are stored, security and encryption, and in the case of Cote d’Ivoire, both manufacturing and ISO format are factored in. Visualization of fingerprints can take place. Initially, Cote d’Ivoire did not keep a visualization of the fingerprints, but due to implementation challenges faced, are considering saving fingerprint visualizations.14 Additionally, Cote d’Ivoire and Nigeria provided insights into their discussions of technology manufacturing standards and aligning to guidelines.13,14 Lastly, Ethiopia noted that building in testing can help with quality assurance and safety measures.16

Legal & Ethical

There have been studies and reviews on the factors to consider for implementing biometrics and perceptions of the community. For example, Using digital health to enable ethical health research in conflict and other humanitarian settings describes the use of digital health in humanitarian settings and discusses factors including costs, society, training, security, inequity, informed consent, data quality, management and protection to consider.27 In addition, A survey of U.S. public perspectives on facial recognition technology and facial imaging data practices in health and research contexts describes findings from a survey on U.S adult perspectives on facial recognition technology and data in health and research. It was found that when asked about eight specific health related uses, there was a “fairly high level of trust in healthcare providers and researchers, … not necessarily fully supportive of expanded uses in healthcare settings…”.28 Lastly, in “Are we getting the biometric bioethics right?” – the use of biometrics within the healthcare system in Malawi views about ethics and best practices on the use of biometrics in the Malawian healthcare system were studied and topics that came about included engaging with stakeholders, having policy makers and implementers involved, equity in rural and urban settings, costs, privacy and confidentiality of data, and engaging the community.29

In addition to perceptions, as discussed in Body identification, biometrics and medicine: ethical and social considerations, there are the legal and ethical components of data collection and storage, including using data for further research.30

For example, Simprints shared their encounter with the topic of the use of incentives for workers when entering data.14 In addition, Haiti, Côte d’Ivoire and Nigeria expressed working with various partners and stakeholders when planning for biometric system implementation. As a result of these discussions in some cases, SOPs were created, workflows were updated, and discussion occurred on how the implementation should be set up. 13,14,15 Côte d’Ivoire noted experiencing hesitation in adopting the implementation from facilities as opposed to patients.14 And lastly, Ethiopia shared that legal points were discussed in regards to processes on regulations and interacting with private facilities that were already in place when planning for various patient identity management system initiatives.16

Costs

The costs of implementing biometrics have been cited as a potential barrier and can include infrastructure, software, technology, implementation and maintenance.31,27

Malawi and Zimbabwe discussed the impact of costs on their considerations for implementation of biometric systems as a next step to their implementation of patient identity management systems.15,19 In addition, Ethiopia noted cost concerns related to the infrastructure, implementation, and maintenance costs of various initiatives, including their biometric initiatives, for patient identity management.16

Lastly, to note, themes illustrated can vary depending on the implementation and there may be a combination.

For example, when Simprints implemented technology, they encountered themes of “community acceptability, step-down training quality, operational vs. technical accuracy, supportive supervision, self-enrollments, duplicate flag by-pass, time consuming record adjudication process and data reconciliation”.14

In addition, Zimbabwe is looking into incorporating biometrics with collection by fingerprint readers and/or iris scanners. When comparing methods, the identified advantages of using biometrics in Zimbabwe included improving patient identification, time savings, accessibility, scalability, and a prototype already being developed. The identified disadvantages of using biometrics in Zimbabwe included implementation and maintenance costs, and infrastructure limitations.19