Effective Use of Existing Mobile Technologies to Augment Simulation-Based Experiences

Authors

Guy C. Gilbert, MS, CHSOS-A, CHSE¹ Kelsey Launer, MPH, CHSE²

Daniel Backlund, PhD, CHSOS, CHSE2

¹ - Texas Tech University, Amarillo, TX

² - Texas Tech University Health Sciences Center, Lubbock, TX

The authors contributing to this work have no conflicts of interest..

Corresponding Author

Guy Gilbert, MSM, MSOL, CHSOS-A, CHSE, Texas Tech University, School of Veterinary, Amarillo, TX (Email: guy.gilbert@ttu.edu)

Abstract

Smartphones and other mobile devices have been among the most disruptive innovations to date due to the cumulation of their capabilities and what they have replaced in the marketplace (i.e., computers, cameras, camcorders, audio recorders, wired telephones, Global Positioning System navigation, barcode scanners, etc.). Mobile device use is becoming more common and necessary to function in routine aspects of modern life. Traditional post-secondary learners that are starting their education have had access to a mobile device since the beginning of their formal/primary education, and their reliance on mobile devices has become a large part of their lives. In a 2021 survey of Americans, 96% of adults between 18-29 years old own a smartphone (Pew Research Center, 2021). Given that mobile devices are ubiquitous among post-secondary learners, potential exists to augment simulation-based experiences with technologies such as quick-response (QR) codes and the near-field communication (NFC) protocol. The Simulation Program at Texas Tech University Health Sciences Center collaborated with the Texas Tech University School of Veterinary Medicine to investigate the implementation of both QR codes and the NFC protocol in immersive simulation-based experiences.

Introduction

Technologies such as QR codes and NFC tags have been utilized since 1994 (S. -H. Hung, 2020) and 1983 (Walton, 1983) respectfully. While NFC is a communication protocol, and a QR code is a machine-readable optical label, both are efficient and effective means of transmitting information to a mobile device through a scanning method. Either method allows a data payload to be sent to a mobile device for interpretation. The mobile device can be configured to process that data and perform an action such as connecting the user to more information like a webpage containing text, pictures, videos, etc. Given the ease of use, both methods described are an efficient way to transmit information to a learner in a manageable and timely manner via a capable device.

Since QR codes are optical, the use of the device’s camera is necessary to translate what is encoded. An unobscured, high-contrast (e.g., Black on white background), 2-dimensional depiction of the QR code is ideal for proper scanning by a camera that is optimally held parallel to the face of the QR code. Nearly all mobile devices on the market currently possess the capability to translate a QR code with the onboard camera application. With the aid of a dedicated QR reading application, a computer can also be used to decode a string from a QR code into a string of text or a web address. The use of a dedicated application can provide a means of simplifying the experience of the end user, as well as providing in-application browsers and caching of files.

NFC is most commonly found in the marketplace, with credit and debit cards, to tap the reading device to make the transaction occur; or hotel keys that only require holding a card near the device to unlock the door; and authentication devices for computers containing sensitive data. NFC is a communication protocol based on radio frequency identification (RFID) technology, but has lower transmission range of 4 centimeters or less. Both RFID and NFC operate on the principle of inductive coupling for short-range implementations. This requires a reader device to generate a magnetic field which allows an electrical current to pass through a coil and return with data to the reader. When an NFC tag (containing its own coil) is within 4 cm to the reader (i.e., when the tag enters the magnetic field), a current is induced in the tag’s metal coil. The NFC protocols and standards dictate that when the handshake between the coil and the reader is complete, the stored data on the tag is wirelessly transmitted to the reader (Subtil, 2014). Many mobile devices currently on the market have NFC reading and writing capabilities made possible by a secure element chip. The major operating systems available on most mobile devices have native support for the NFC protocol. Windows introduced support for NFC in their Windows 8 release in 2012 (Warren, 2012). Apple added NFC implementation into their iOS platform in 2014 (Apple, 2021). Android, Inc. implemented native support for NFC in their Android 4.4 release in 2013(Android Developers ).

Applicable Uses of QR Codes and NFC Tags in Simulation-Based Experiences

With the capabilities that these wireless protocols provide, it is possible to standardize assessment points such as a string of text, audio, still images and video. From a simulation operations standpoint, the capabilities of these protocols provide a potential means to save time on set-up, negate the need for moulage, or introduce capabilities to the simulation that had not previously been possible. From a simulation educator standpoint, a QR code or NFC tag can provide reliable, consistent, standardized information to be replicated and easily distributed throughout all modalities of simulation. These protocols can also allow learners the ability to discover codes/tags during the patient's physical assessment, interpret findings, and diagnose based on what information they have been provided. Some example applications of QR codes and NFC tags in simulation are listed below.

• Provide a standardized verbal report / handoff / SBAR / intake note / door sheet
• Allow visible assessment points to be discovered upon examination (i.e.- rash on the torso)
• Auscultation sounds at different points (introduce a uniform sound for a systolic murmur)
• Intended result for blood pressure, SpO2, blood sugar, etc.
• Present visuals of patient monitors or user interfaces for medical equipment (i.e. – IV pump settings, or ventilator settings)
• Represent hazards or safety concerns, without it actually being a safety concern
• Invasive exams (HEENT, rectal, vaginal)
• Difficult or Acute presentations (burns, complex disfiguring injuries or active bleeding)
• Add diversity with images or video to represent the intended patient or family members
• Chaperoned or sensitive examinations of genitals
• Ambulatory exam / reflexes (visualize the lameness in the gait of a horse or a particular balancing failure during a concussion evaluation)
• Timely diagnostic reports / results
• Timely diagnostic imaging X-ray / ultrasound
• Cues such as bruising, needle tracks, or tattoos on the patient or family members
• Present a trigger film to learners

Development of a Progressive Web Application for Scanning QR Codes

A progressive web application (PWA) was developed to aid in the use of QR codes in simulations and testing environments. Development of the PWA was done using a collection of Bootstrap, HTML5, CSS, JSON and jQuery. PWAs are websites that work as a traditional website but are also progressively enhanced with offline capabilities and cross-platform interoperability to operate like a native app when installed on a mobile device (MSEdgeTeam, 2022). The aim of the PWA development was to create an installable application that was easy for learners to use, could translate QR codes, have a non-caching in-app browser, and could be locked (using guided access on iOS, or screen pinning on Android) to prevent learners from visiting other applications. The ability to lock the PWA allows exam proctors the ability to guide and control mobile devices during summative events. 

Figure 1: Screenshot of the Progressive Web Application in the mobile device’s default browser.

Using and Trialing the Application with QR Codes

The PWA has been used in numerous simulations in healthcare and veterinary settings since 2020. Scenarios have included human trafficking simulations where QR codes were placed to represent bruising, evidence of abuse, sexually transmitted diseases (STDs) and tattoos on standardized patients. QR codes have also been extensively used in head, ear, eye, nose, and throat exams in OSCEs in our medical school. They have also been applied in veterinary simulations for auscultation sounds, visual assessment, depiction of the animal’s environment as well as cues that are present in the animal’s environment. The option to lock and limit functionality to the PWA on a mobile device (using guided access on iOS, or screen pinning on Android) has potential value for testing experiences.

Students and faculty expressed that the utilization of the QR codes has made the simulations flow better, eliminated the distraction and awkwardness of scripted responses, and errors related to documents and finding cards being exchanged during OSCEs. The faculty also appreciate how the use of QR codes has allowed learners to interpret findings rather than being given deciphered descriptions.

Trauma scenarios have also utilized QR codes to represent injuries and trauma that has allowed standardization across duplicated scenarios, as well as saving time by eliminating the need for moulage and clean up. Codes were beneficial in providing X-ray and sonography imaging in a quick and efficient method. Instructors and students have appreciated the use of QR codes in these scenarios and felt that it provided a better depiction of the severity of the cases.

Using and Trialing NFC Tags in Simulations

NFC tags are inexpensive and readily available at consumer outlets in a variety of styles, ranging from small adhesive stickers to credit card-sized plastic tags. The tags we utilized can either be disposable or reusable, flexible or rigid, and can typically be written and rewritten with up to 504 bytes of data by NFC authoring apps that can be installed on any smartphone. The versatile design of the tags makes it easy to place them practically anywhere on standardized patients, animals, equipment, simulators and task trainers. Tags are still functional when placed beneath clothing or a simulator’s skin. Larger NFC tags can be given to learners as finding cards at appropriate times or when prompted in response to their examination or particular intervention. The use of coin-sized plastic NFC tags has worked the best for most of our applications. The coin sized tags are comfortable for SPs to wear, easy to label and can be held in place with Tegaderm dressing or medical adhesive.

NFC tags were utilized on SPs and simulators in simulation based education to supplement and augment the simulation as points of physical assessment. 6 NFC tags were placed at respective assessment points to deliver auscultation sounds and visual cues in the same human trafficking simulation in which the QR codes were used. 35 learners were able to easily access the web resource that the NFC tag was programmed to deliver by momentarily holding their unlocked

smartphone within 4 cm of the tag, without the need for a dedicated application. The scanning of the NFC tags allowed a quick and seamless assessment for the learner as they discovered things such as bruising, evidence of abuse, STDs, and tattoos on the standardized patients at points where dime-sized NFC tags were placed. NFC tags were labeled identifying which case they were associated with and the location on the patient where they should be placed for set-up and later reuse. When a student successfully scanned an NFC tag, a banner-style notification appeared on the screen of the mobile device. Upon clicking the notification, the learner was directed to the web resource by the mobile device’s default browser. In order to scan another NFC tag, the learner simply repeated the process and was directed to a new web resource with a single tap. The NFC tags utilized were rewritable (with an option of being password protected) and were programmed utilizing an application titled NFC tools (available on Google Play and the App Store). Specifications of the NFC tags were that they were 2.5 cm in diameter, contained the NFC 215 chip, had a polyvinyl chloride (PVC) waterproof exterior, could hold 504 bytes of data, and cost $0.30 each. The only challenge presented through the use of NFC tags was labeling tags for the ability to apply and place them properly to the SP, and for later reuse.

Comparing QR Codes to NFC Tags

Through the trialing of these two technologies there were benefits and shortcomings to both. The NFC tags in simulation-based experiences have the potential to be easier and faster to utilize, since a smartphone can read and prompt navigation to a webpage in one click without the need for an application or camera. Since no application is needed to scan the NFC tag, the web resource encoded into the NFC tag is opened in the default browser and caches the data supplied. In our simulation, the ability to reuse the NFC tags was a benefit over the need to reprint QR codes for subsequent repetitions of the simulation. NFC tags are a fast and efficient method of getting information to a learner, but the use of the default browser on the smartphone does make it more difficult to prevent data from getting cached on a device. This could affect the integrity of testing materials in summative evaluations. The reproduction of QR codes is a quick process when a QR code encoder is available, while the process of programming NFC tags can be more time consuming and has additional steps compared to printing QR Codes. Through the use of QR codes in conjunction with our QR reading PWA, it is easier to control the dissemination of information provided by the QR code. The PWA is beneficial in maintaining the integrity and security of summative evaluations, since no data or URLs are stored or cached.

Feedback from end users

Feedback on QR codes has primarily come through a contact form available in the PWA, and from what has been shared in dialogue between students and faculty following the simulations in which the codes were utilized. Feedback shared regarding the use of QR codes without the use of the PWA that it is cumbersome, slow and requires 2 or more apps to decipher the QR code. Students who did use the PWA were complimentary of its functionality and delivery of assessment findings. The constructive criticism received has been in regard to issues with loss of internet connection and connection speeds, which limit or impair the function of the PWA, but are not directly associated with the function of the PWA itself or the QR codes.

Feedback regarding NFC tags was captured through shared dialogue between learners and faculty and was very complimentary of its speed and ease of use. Criticism of NFC Tags included the current inability for use in summative testing and that many tablets are not capable of reading NFC tags.

Conclusion

While there is still so much to explore in the use of QR codes and NFC tags to augment simulations, both technologies provide innovative means of expanding and standardizing simulations in ways that were otherwise difficult to do. Learners and educators expressed that both technologies were easy to use, applicable to simulation, and their experiences were satisfactory. Both of these technologies allow for more immersive, standardized, and accurate simulation-based experiences and assessments. We are continuing to explore potential solutions for both QR codes and NFC tags in simulation.

References

Android Developers. (2023). Near field communication overview: android developers. https://developer.android.com/guide/topics/connectivity/nfc.

Apple. (2021). Official Apple Support. https://support.apple.com/kb/sp705?locale=en_

MSEdgeTeam. (2022). Overview of progressive web apps (pwas) - microsoft edge development. Microsoft Edge Development | Microsoft Learn. https://docs.microsoft.com/en-us/microsoft-edge/progressive-web-apps-chromium/.

Pew Research Center. (2021, April 7). Mobile fact sheet. Pew Research Center: Internet, Science & Tech. https://www.pewresearch.org/internet/fact-sheet/mobile/.

S. -H. Hung et al., "Micrography QR Codes," in IEEE Transactions on Visualization and Computer Graphics, vol. 26, no. 9, pp. 2834-2847, 1 Sept. 2020, doi: 10.1109/TVCG.2019.2896895.

Subtil, V. (2014). Near field communication with Android cookbook. Packt Publishing Ltd.

Walton, C. (1983, May 17). US4384288A - portable radio frequency emitting identifier. Google Patents. https://patents.google.com/patent/US4384288A/en.

Warren, T. (2012, June 20). Windows phone 8 in detail: New start screen, multi-core support, VoIP integration, and NFC. The Verge. https://www.theverge.com/2012/6/20/3096667/windows-phone-8-screenshots-features-nfc-start-screen-dual-core