Scan and share to register outpatients, India

Abstract

Problem

To address the long waiting times patients incur when visiting outpatient departments in India.

Approach

In 2022, the National Health Authority in India developed a paperless service, called Scan and Share, leveraging mobile technology and QR (quick-response) codes to streamline outpatient department appointments. Patients can use a mobile application (app) to scan QR codes at health facilities, generating tokens linked to registration counters. The service integrates patients’ demographic data from their Ayushman Bharat Health Account with the facilities’ health information systems. Collaboration with government bodies, health workers and patient advocacy groups ensured compliance with data protection regulations. For developers, the National Health Authority published detailed technical specifications outlining standards for app functionality, security and interoperability on the Ayushman Bharat Digital Mission platform.

Local setting

Launched in 2021, Ayushman Bharat Digital Mission in India aims to digitize health care, creating a shared digital infrastructure for affordable and accessible care.

Relevant changes

As at 19 October 2024, the Scan and Share service operates in 16 939 health-care facilities across 35 states and territories. The service has reduced waiting times from 1 hour to 2–5 minutes. Out of 56 801 213 tokens generated, 714 014 (1.3%) were issued in the private sector. There are currently 2074 active developers, with 1545 from the private sector.

Lessons learnt

The Scan and Share service is transforming health-care delivery by reducing outpatient department queues, waiting times and errors. High-performing states can provide valuable insights for states with low service adoption.

Introduction

A well-functioning health-care system delivers high-quality services to the population, ensuring it is accessible, affordable and sustainable over time.¹ In India, a concern for patients visiting secondary and tertiary care hospitals is the long queues for registration, causing considerable delays, and often forcing patients to return the next day. These delays are primarily due to manual data entry, errors in such entries and insufficient staff. To address this problem, the National Health Authority in India introduced a paperless service, called Scan and Share, which leverages mobile technology and QR (quick-response) codes to streamline outpatient department appointments. Through this service, patients can scan a facility’s unique QR code to register at the outpatient department. With their consent, they can also allow health workers access to their health records stored in the facility's hospital management information system. Here we describe how the Scan and Share service seeks to simplify health-care access for citizens visiting outpatient departments.

Local setting

In 2021, the Indian government launched the Ayushman Bharat Digital Mission to digitize all health-care services and build a common digital infrastructure for low-cost and seamless health-care service delivery in India.² The mission, governed by the health ministry and implemented by the National Health Authority, is funded by the Indian government with support from both the public and private sector.

The mission has implemented six building blocks: (i) Ayushman Bharat Health Account identifier (ID), a voluntarily generated 14-digit unique personal ID that can be used across health-care facilities; (ii) individual-controlled personal health record applications (apps) that enables patients to securely view, link and share their medical records; (iii) a health professional registry, which serves as a comprehensive repository of all health workers across modern and traditional medicine systems; (iv) a health facility registry, a comprehensive directory of health facilities across various medical systems; (v) a drug registry; and (vi) a unified health interface providing open protocols that create an interoperable network of digital health services between facilities for patient-centric services.³ The interface offers diverse health record apps that users can download to explore services and facilities, book appointments and pay for health-care services. The replicability of unified health interface resembles the unified payments interface, used for instant payment, which has been successfully adopted in India.³

Additionally, technologies such as barcodes, QR codes, blockchain technology and radio frequency identification tags are being used to enhance the digital health-care infrastructure.

Patients’ health data are stored locally within each facility's system, ensuring compliance with data protection regulations and Ayushman Bharat Digital Mission protocols.

Approach

To reduce errors and expediting registration in hospital outpatient departments, the National Health Authority created a Scan and Share service in 2022. This service enables paperless registration and, with user consent, the service also supports secure sharing and real-time access of health records.⁴

Throughout the project, the authority consulted with government bodies, health-care providers and advocacy groups, assessed health facility infrastructure readiness, ensured data protection compliance and collaborated with the health ministry for regulatory approvals. The authority collaborated with about 30 hospital management information system vendors for integrating QR code functionality into existing hospital systems. The Advisory Group of the Ayushman Bharat Digital Mission, comprised of digital health experts and policy-makers, ensured that the project aligned with national health goals and standards.

For designing, testing and implementing the Scan and Share service, the National Health Authority contracted public and private technical developers specializing in digital health and interoperability. For interested app developers, the authority developed and published detailed technical specifications outlining standards for personal health record apps functionality, security and interoperability on an open application programming interface framework on the Ayushman Bharat Digital Mission platform. This interface framework provided a sandbox environment, allowing developers to test their apps with simulated data to ensure compliance with the digital mission’s ecosystem. Each app underwent a certification process to meet digital mission standards for data privacy, encryption and user interface. Only certified apps were authorized for use, and standardized QR codes had to be unique, secure and compatible with various health facilities.

Before and during implementation, the National Health Authority conducted structured training sessions at various levels, including state governments, chief medical officers and facility managers. Virtual training sessions on Scan and Share service are held monthly for doctors, nurses and data entry operators. To educate health workers and patients on the registration process and increase understanding of the service, the authority organized awareness campaigns, using instructional videos, posters and banners, and conducted various outreach activities. Top-performing states share their practices with other states through cross-learning sessions. At the health facilities, health workers regularly received technical support and doubt-clearing sessions from the authority.

Facility staff also received training on the hospital management information system, which is provided by a combination of government health authorities, system vendors and companies specializing in health-care software.

To ensure that all patients have access to the Scan and Share service, the authority created two options to register at the outpatient department, either with a smartphone or using an Ayushman Bharat Health Account card (Box 1). People using a smartphone access the service through a personal health record app linked to their Ayushman Bharat Health Account.⁵ When patients scan a health facility's unique QR code, their health account is accessed through the cloud services of the National Health Authority. Using the demographic data in the account, the app generates a token linked to the facility or to a specific counter, such as those for elderly patients.⁵ Patients without a smartphone can use their Ayushman Bharat Health Account card, which displays a QR code. This code can be scanned at the registration desk to retrieve their demographic data from the health account. Patients without a card can generate one at dedicated hospital kiosks.

Box 1. Options for patients to scan the QR code.

For patients with smartphones

The patient scans a QR code at the outpatient department registration counter, which directs them to the Ayushman Bharat Digital Mission-enabled personal health record app on their smartphone. The profile-sharing page appears in the app, and after the patient provides consent and clicks on the share button, the details linked to their Ayushman Bharat Health Account are sent to the health facility’s health management information system, completing the express registration. A waiting number, a so-called token, is generated and displayed on the app, allowing patients to wait for the number to appear on the registration screen. The token is valid for 60 minutes. At the counter, patients are asked basic health questions and a consultation slip is generated before patients are directed to a specific department.

If the patient does not have a personal health record app, a list of compliant apps is displayed after scanning the QR code. The user can select any application to download, and they can also create an Ayushman Bharat Health Account ID if needed.

Patient lacking access to a smartphone or other digital tools

Patients can obtain an Ayushman Bharat Health Account card at dedicated hospital kiosks, where it is created using biometric or face authentication. The Ayushman Bharat Health Account card displays a patient-specific QR code, which the patient can scan at the registration counter, allowing the hospital's health management information system to access the patient’s demographic data. The patient then proceeds to the required department for consultation with their outpatient department slip.

To be able to provide the Scan and Share service, hospitals need a hospital management information system compliant with the Ayushman Bharat Digital Mission standards, dedicated counters, token display boards, announcement systems and QR codes for patients to register. The hospital management information system links with Ayushman Bharat Health Account through the unique ID for follow-up patients, assigns new unique health IDs to first-time users, and sets token expiration time. To be able to generate QR codes for registration, hospitals must register with the health facility registry. For health workers to access a patient’s health records after consent, they must register with the health professional registry.

The Scan and Share service was implemented using funds from the Ayushman Bharat Digital Mission budget, with a total cost of 16 billon Indian rupees (190 240 000 United States dollars) over five years. This funding covered the infrastructure setup, software deployment and operational expenses required to implement the system. The service is offered free of charge to patients and facilities.

Relevant changes

The Scan and Share service has been adopted by 35 out of 36 States and Union Territories of India, and is of October 2024 operational across 16 939 health-care facilities. More than 50 million tokens have been generated, reducing waiting times from 1 hour to 2–5 minutes. An average of 220 000 individuals use the service daily.⁶ The number of tokens generated varies across different states, with government facilities contributing to a greater share. Out of 56 801 213 tokens generated, 714 014 (1.3%) were issued by the private sector. The number of Ayushman Bharat Health Account IDs created also varied across the country (Table 1). More than half of these accounts have been issued to individuals aged 19–45 years. Additionally, 410 million health records have been linked to health account IDs.

Table 1. Number of Ayushman Bharat Health Account created and Scan and Share tokens generated, India, 19 October 2024.

State or union territory	Population	Health accounts created, no (%)	No. (%) of tokens generated
			Total	Government facilities	Private facilities
Uttar Pradesh	238 875 000	112 046 330 (46.9)	9 593 365	9 548 865 (99.5)	44 500 (0.5)
Maharashtra	127 684 000	52 720 069 (41.3)	719 605	716 419 (99.6)	3 186 (0.4)
Gujarat	72 653 000	45 670 972 (62.9)	347 810	345 318 (99.3)	2 492 (0.7)
Madhya Pradesh	87 954 000	44 986 998 (51.1)	1 095 793	1 093 021 (99.7)	2 772 (0.3)
Andhra Pradesh	53 402 000	41 432 145 (77.6)	5 669 164	5 668 903 (100.0)	261 (0.0)
West Bengal	99 723 000	35 478 690 (35.6)	186 538	186 504 (100.0)	34 (0.0)
Bihar	129 205 000	38 283 076 (29.6)	1 142 096	1 141 706 (100.0)	390 (0.0)
Rajasthan	82 188 000	34 688 959 (42.2)	74 695	74 667 (100.0)	28 (0.0)
Karnataka	68 256 000	28 351 246 (41.5)	4 103 190	4 091 793 (99.7)	11 397 (0.3)
Odisha	46 663 000	26 162 859 (56.1)	474 358	473 609 (99.8)	749 (0.2)
Chhattisgarh	30 638 000	21 296 619 (69.5)	680 244	680 136 (100.0)	108 (0.0)
Telangana	38 317 000	19 626 176 (51.0)	192 087	191 851 (99.9)	236 (0.1)
Assam	36 159 000	18 177 557 (50.3)	354 285	354 244 (100.0)	41 (0.0)
Kerala	35 967 000	17 622 631 (49.0)	1 243	1 219 (98.1)	24 (1.9)
Jharkhand	40 129 000	13 801 170 (34.4)	91 946	91 838 (99.9)	108 (0.1)
Haryana	30 694 000	13 991 898 (45.6)	224 163	20 (0.0)	224 143 (100.0)
Punjab	30 992 000	12 949 207 (41.8)	129 093	129 026 (99.9)	67 (0.1)
Tamil Nadu	77 165 000	12 418 244 (16.1)	151	101 (66.9)	50 (33.1)
Jammu And Kashmir	13 733 000	8 843 954 (64.4)	3 789 983	3 789 953 (100.0)	30 (0.0)
Delhi	21 884 000	8 306 527 (38.0)	2 139 972	2 139 400 (100.0)	572 (0.0)
Uttarakhand	11 795 000	6 740 933 (57.2)	214 717	214 697 (100.0)	20 (0.0)
Himachal Pradesh	7 518 000	5 917 464 (78.7)	367	365 (99.5)	2 (0.5)
Tripura	4 194 000	1 739 843 (41.5)	130 255	119 412 (91.7)	10 843 (8.3)
Puducherry	1 695 000	1 120 109 (66.1)	5 755	5 749 (99.9)	6 (0.1)
Meghalaya	3 387 000	1 081 796 (31.9)	23 784	23 784 (100.0)	0 (0.0)
Manipur	3 260 000	891 325 (27.3)	10 347	10 286 (99.4)	61 (0.6)
Goa	1 585 000	841 942 (53.1)	2 087	2 071 (99.2)	16 (0.8)
Chandigarh	1 247 000	698 574 (56.0)	102 339	102 334 (100.0)	5 (0.0)
Dadra and Nagar Haveli & Daman and Diu	1 387 000	683 275 (49.3)	279	279 (100.0)	0 (0.0)
Nagaland	2 258 000	677 180 (30.0)	NA	NA	NA
Mizoram	1 252 000	638 527 (51.0)	4	1 (25.0)	3 (75.0)
Sikkim	697 000	414 008 (59.4)	5 264	5 264 (100.0)	0 (0.0)
Arunachal Pradesh	1 580 000	357 539 (22.6)	10 211	10 211 (100.0)	0 (0.0)

NA: not available.

Several rounds of training have been held, covering health account ID creation, record linking, data privacy, consent management and system integration to ensure secure, interoperable health data management. As of November 2024, 204 government and private partners are creating Ayushman Bharat Health Account IDs, with 126 of them (93 from the private sector) linking patients’ health records to their health account IDs.

Downloaded state-wise data up to 19 October 2024, from the Ayushman Bharat Digital Mission public dashboard,⁷ showed that 341 973 health facilities were registered in the health facility registry, with 56.5% (193 348) being public facilities. Of the 486 879 health workers registered in the health professional registry, 40.4% (196 861) are doctors, 71.0% (345 684) from the government sector and 29.0% (141 195) from the private sector.

There are currently 2074 active developers in the sandbox environment, with 1545 from the private sector. Among 131 partners that have successful integrated with the digital health ecosystem, 111 (84.7%) are from the private sector.

Lessons learnt

The Scan and Share service is transforming health-care delivery in India by reducing outpatient department registration queues and waiting times, benefiting vulnerable groups, and addressing inefficiencies and errors in manual data entry (Box 2). The open, standardized and secure interface framework, combined with the service’s interoperability, scalability and user-centric design have facilitated widespread adoption and integration across the health system. These features also support other QR code-enabled services, such as Scan and Send, and Scan and Pay, allowing patients to directly pay for laboratory tests and medications through the app. Therefore, the National Health Authority is now expanding its implementation to pharmacies and laboratories.

Box 2. Summary of main lessons learnt.

• The Scan and Share service reduced waiting times for outpatient department registration

• By integrating the service into hospital management systems, health-care facilities experienced reduced manual data entry errors and lowered administrative burdens

• Challenges in limited digital infrastructure, unreliable internet connectivity and training needs are addressed with a financial incentive scheme

To boost adoption in states with low uptake, digital literacy, access to digital devices and health information systems, internet connectivity and infrastructure needs to be addressed, alongside targeted training for health workers and patients. Valuable insights and best practices from high-performing states can guide policy-makers in accelerating implementation and facilitating state-level adoption. Other challenges include limited private sector adoption, delays in policy implementation, fragmented information streams from multiple digital platforms and interoperability issues between the health information system and the sandbox interface. The National Health Authority is addressing the limited digital infrastructure, unreliable internet connectivity and training needs by offering financial incentives through the Digital Health Incentive Scheme.

India’s vast population, federal structure and cultural diversity present unique challenges to health-care provision. However, recent strides in digitally transforming the health sector have laid a foundation for continued growth and digital transformation.