32nd Annual International Conference of the IEEE EMBS

Buenos Aires, Argentina, August 31 - September 4, 2010

Embedding Patients Confidential Data in ECG Signal For HealthCare

Information Systems
Ayman Ibaida, Ibrahim Khalil and Dhiah Al-Shammary
School of Computer Science and IT
RMIT University
Melbourne, VIC 3000, Australia
ayman.ibaida@student.rmit.edu.au, ibrahimk@cs.rmit.edu.au, d.alshammary@student.rmit.edu.au

2
Abstract— In Wireless tele-cardiology applications, ECG sig-

nal is widely used to monitor cardiac activities of patients.
Accordingly, in most e-health applications, ECG signals need to
be combined with patient confidential information. Data hiding
and watermarking techniques can play a crucial role in ECG
wireless tele-monitoring systems by combining the confidential
information with the ECG signal since digital ECG data is
huge enough to act as host to carry tiny amount of additional
secret data . In this paper, a new steganography technique is
proposed that helps embed confidential information of patients
into specific locations (called special range numbers) of digital
ECG host signal that will cause minimal distortion to ECG,
and at the same time, any secret information embedded is
completely extractable. We show that there are 2.1475 × 109
possible special range numbers making it extremely difficult
for intruders to identify locations of secret bits. Experiments
show that percentage residual difference (PRD) of watermarked
ECGs can be as low as 0.0247% and 0.0678% for normal and
abnormal ECG segments (taken from MIT-BIH Arrhythmia
database) respectively.
I. I NTRODUCTION
Steganography is the communication art of sending and
receiving secret messages that are hidden inside a specific
host content such as images, waves, and videos [1]. In other
words, steganography can be defined as hiding technique that
is able to embed secret data inside another data host in such
a way that prevents unauthorized persons to access the secret
message [4]. In recent years, data hiding models are gain-
ing popularity in establishing more secured communication
channels for delivering secret messages [3] since there is
huge demand for sending sensitive information over the net.
In most wireless health care systems, patients are monitored
continuously using body sensors in order to collect their
physiological signals and send them to the hospital servers
over the internet. This enables the physicians to take fast
action in case of any emergency situation.
ECG signal as shown in fig 1 is an electric signal that
is generated by the heart which is used by cardiologists to
diagnose the heart functionality [8] . If a patient with heart
abnormality is remotely monitored, then with 12 lead ECG,
10 bit Resolution and 360 Hz Sampling Frequency the data
can easily reach up to 2.77 GB in one day. The enormous
volume of digital ECG samples has the ability to serve as
a data host material for hiding confidential information of
patients. In a typical wireless telemonitoring scenario for
remote cardiac patients wireless e-health systems send ECG
978-1-4244-4124-2/10/$25.00 ©2010 IEEE
Amplitude (mV)
0
−2
−4
0 500 1000 1500 2000 2500
Number of Samples
Fig. 1. Typical ECG signal for Tachycardia Affected Patient With a Heart
Rate of 200
signals of patients and their personal information separately
to the hospital servers without any protection. However,
The Health Insurance Portability and Accountability Act
(HIPAA) of 1996 in US mandates that confidential and
private information related to patients be protected and sent
over the net and stored in a secured manner. In this paper, a
steganography technique as shown in Fig. 2 is proposed that
allows ECG samples to be gathered on a wireless mobile
device and sent with patient sensitive personal information
such as name, age, personal ID, etc. At hospital servers,
patients data can be extracted from the received ECG signal
[5].
The challenge of the proposed steganography algorithm,
is to preserve the physical features of the ECG signal and
guarantee the success of the diagnosis process of the ECG
signal after extracting the hidden data. In this paper, the
evaluation of the proposed technique is based on computing
the PRD error measurement as a way to show the ability of
diagnosing the host ECG signal. In summary, this paper tries
to answer the following research questions:
• How can the ECG signals be used efficiently to achieve
high level of security in sending and receiving the
patients confidential information ?
• Can the resultant ECG host signals provide the same
physiological features as the original one?
The rest of the paper is organized as follows. In section II
we discuss the related work that has been done in this area.
Section III discusses the proposed steganography technique.
Then, section IV shows the evaluation of the ECG host
signals. Finally, section V concludes the paper.
II. R ELATED WORK
Although there is a large volume of works on watermark-
ing and steganography, not many researchers have addressed
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 Raw Patient’s
ECG Signal
Smartphone
Watermarked
ECG Signal
Patien with
ECG sensor
Internet
Hospital server will
extract the information
and distribute it to
Extracted patient
the different doctor
information
seperated from
devices
ECG signal
Desktop Tablet Laptop PDA
Fig. 2. Watermarking ECGs in Body Sensors Enabled Mobile Health Care
Systems
issues related to ECG data. In [6] Mohammed Nambakhsh
and Alireza Ahmadian used the ECG signal as a secret
data, and embedded it inside medical images like CT and
MRI. Other researchers [2] implemented a wavelet based
watermarking technique for ECG signal. To achieve this they
first decomposed ECGs up to level 3 to divide them into 8
bands, and then computed the average power for each band
and used the calculated power as threshold parameters. They
selected sub-bands to add the watermark to it according
to the threshold values. Finally, inverse Digital Wavelet
Transform (DWT) is applied to reconstruct the watermarked
ECG signal.
In all the above techniques the algorithms have high com-
putation complexity. Since some transforms must be done,
these operations require a high amount of computational
resources and will incur delay in generating watermarked
signal. Since we are limited in resources and power, a simple
power preserving technique is required for steganography
process.
III. T HE METHODOLOGY
As mentioned already, in recent e-health systems the usage
of ECG signal has increased significantly to provide highly
qualified remote medical services. In this paper, a new
steganography technique is proposed that is able to hide the
secret message in any position in the host signal without
distorting the original signal. This technique provides high
security for the secret message by selecting more secured
positions (such as MSB) in the host ECG signal that are
unexpected to the intruders. The proposed model consists of
four sequential steps as shown in Fig. 3.
A. ECG Signal Preprocessing
The first step is responsible of shifting up and scaling the
ECG signal to avoid the negative values and converting the
signal floating point numbers into integers. At the same time,
the function of this step represents the fist level of security
of the steganography technique by hiding the values of both
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ECG signal ECG signal
Shift special Data hiding
preprocessing Scale and level
range Transform
correction
ECG Signal special range
Secret Bits ECG Signal with
parameters
secret bits
Fig. 3. Block Diagram for the Proposed ECG Steganography System
shifting and scaling factors that are mandatory parameters
for extracting the secret information. Equation 1 is required
for shifting up the ECG signal samples.
X̄ = s + X (1)
Where X̄ is the shifted ECG signal, s is the shift value
and X is the original ECG signal. Then, the resultant shifted
signal is scaled to compute the integer version of the ECG
signal. Equation 2 is required to perform the scaling function.
b = p ∗ X̄
X (2)
Where X b is the scaled ECG vector, p is the scale factor and
X̄ is the shifted ECG vector. Technically , the value of p is
based on the ECG sample precisions of the ECG acquisition
device and the ADC converter (analogue to digital).
B. Shift Special Range Transform
In our proposed system, a number of special values in the
ECG signal samples are found to be relevant hosts that can
hide the secret bits in the most significant positions with the
condition of inverting the values of the right hand bits to
the secret bit position. At the same time, these special host
values do not produce large errors as a result of the hiding
operation. Let M = 128 be a special value that allows us to
hide the secret bit B in the 8th position of binary value of
M . By computing the binary representation of M , we get
(10000000)2 . If B = 1, then the special value of M will not
be changed as the 8th bit of M is already equal to 1. On
the other hand, if B = 0, conversion of the 8th bit of M to
zero will cause a dramatic change to the host value as the
new value of M will be equal to 0 (00000000)2 . However, by
applying the condition of inverting all the right hand side bits
of the secret position(in this case right of 8th bit), the new
value of M will be 127 which is equivalent to (01111111)2 .
As a result, this process will reduce the resultant error to 1.
For our ECG host signal, we use 32 bits to form each ECG
sample. In this binary format, there are many special ranges
that are relevant to hide the secret bits in all host sample
positions. Equation 3 calculates the total number of special
ranges that can be used.
i=r
X
T = 2r−i (3)
i=2
Where T is the total number of special ranges, i is the
position of the secret bit, and r is the total number of bits
per sample. By applying Equation 3, and setting r = 32,
the resultant T is 2.1475 × 109 .
 TABLE I
very large possibilities of the available special ranges that is
S PECIAL RANGES FOR DIFFERENT POSITIONS
up to 2.1475 × 109 and pre-processing parameters such as
Rmin Rmax n Position 232 possible shifting values and few possibilities of scaling
127 129 3 8 values 200 for MIT-BIH data. Therefore, even if we ignore
32767 32769 3 16
8388607 8388607 3 24
scaling factor, the intruder needs to try this very large number
2147483647 2147483649 3 32 of possibilities (i.e. 2.1475 × 109 × 232 ) to enable him to
extract the secret message from host ECG samples.
011001110110100111
101111101010000110 IV. R ESULTS AND D ISCUSSIONS
100011000111011000 A testbed of 81 ECG segments has been set up by
101010111110001010 collecting ECGs from The Creighton University Ventricular
Tachyarrhythmia Database [7]. Each ECG segment has a
Fig. 4. The Secret Binary Data length of 10 seconds with 250Hz sampling frequency and
consists of 2500 samples. In this paper, secret bits have been
hidden in different positions (8th,16th,24th, and 32nd bits)
With the aim of utilizing all the ECG signal samples as using four special ranges. To evaluate the proposed steganog-
host for the secret bits, in the second step of the proposed raphy technique, the resultant ECG signals are compared
technique (Shift range transform) a new shifting transform with their original signals. The percentage residual difference
is proposed to shift any number in the host signal to any (PRD) is computed using equation 6.
required special range number. Equation 4 is required to v
uX
perform the shifting operation to the host signal sample. u N
u (xi − yi )2
u
u
S = Rmin + (M mod n) (4) P RD = u i=1 N (6)
u X
t x2
Where S is the new shifted value, Rmin is the starting i
value of the target special range, M is the value of the host i=1

signal sample and n is the length of the special range. Table
I shows some examples of special ranges that we used to
hide bits in positions 8,16,24 and 32.
C. Data Hiding
The third step of the proposed technique is the actual data
hiding process. The basic idea of this process is to hide the
secret bits using the shifted value as a host, then the resultant
value would be shifted back to its original level. Equation 5
is required to perform the hiding processes.
(
Mo + (Rmax − S) if B=1
Mn = (5)
Mo − (S − Rmin ) if B=0
Where Mn is the new resultant value of the host data,
Mo is the original host signal sample, Rmin is the minimum
value of the selected special range, Rmax is the maximum
value of the selected special range and B is the secret bit.
Fig 4 shows a block of the secret bits that were inserted
into the host signal samples of ECGs.
D. ECG Signal Scaling and Level Correction
The final step of the proposed technique is to de-scale
the signal and shift it back to its original values. To extract
the hidden data from the host signal the receiver needs
to know two parameters, the used range and signal pre-
processing parameters. The receiver should apply the same
transformation using equation 1 in addition to performing
bitwise operation to extract the secret bits located in special
range values of ECG host samples. Consequently, only
authorized persons know this information can extract the
hidden data. The strength of this approach is based on the
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Where x is the original ECG signal, and y is the resultant
watermarked signal.
TABLE II
D IFFERENT PRD VALUES FOR D IFFERENT RANGE LENGTHS
number of changed LSB Range Length PRD
0 2 0.02
1 4 0.0735
2 8 0.1946
3 16 0.4493
Fig 5 shows eight ECG segments divided into two groups,
where the first group contains the original normal ECG
segment and three resultant host signals when we applied
different special ranges and had data hidden in secret bit
positions(see table I). The second group contains the original
abnormal ECG segment in addition to three resultant host
signals using the same special ranges and secret bit positions
that we used in the first group. This figure shows that despite
hiding in different secret positions, PRD error measurement
remains very low and same for all cases of the same ECG
signal. However, PRD error measurements vary slightly for
normal and abnormal groups of host ECG signals. This
fact of being able to generate a constant PRD value using
different bit positions is a powerful characteristic of the
proposed steganography technique that enables the users to
hide their secret messages in highly secured positions without
affecting the important features of the ECG signal.
The evaluation of the proposed technique show the
strength of the hiding model by performing simulated attacks
to prove the ability of extracting the embedded data com-
pletely although the least significant bits of the host signal
 Abnormal Original ECG Normal Original ECG
1 4

0 2

−1 0

−2 −2
0 200 400 600 800 1000 0 200 400 600 800 1000

Abnormal, data hidden in bit position 8 PRD=0.0678% Normal, data hidden in bit position 8 PRD=0.0247%
1 4

0 2

−1 0

−2 −2
0 200 400 600 800 1000 0 200 400 600 800 1000

Abnormal, data hidden in bit position 24 PRD=0.0678% Normal, data hidden in bit position 24 PRD=0.0247%
1 4

0 2

−1 0

−2 −2
0 200 400 600 800 1000 0 200 400 600 800 1000

Abnormal, data hidden in bit position 32 PRD=0.0678% Normal, data hidden in bit position 32 PRD=0.0247%
1 4

0 2

−1 0

−2 −2
0 200 400 600 800 1000 0 200 400 600 800 1000

Fig. 5. Different Cases of Watermarked ECG Signals After Hiding Secret Information in Bit 8,24 and 32 of Binary ECG Data

have been changed deliberately. Table II shows several cases
of the simulated attacks on the host signal and the required
range lengths to protect the embedded data in addition to the
resultant PRD of each case. For example, if the first LSB
is changed, then a range length of 4 is required to protect
the secret hidden bits. Moreover, if the least two significant
bits are changed, a range length of 8 is required to achieve
the secret bit’s protection. Finally, a range length of 16 is
required to protect the secret message from changing the fist
three LSBs. As shown in Table II, the PRD values will be
increased when the number of the changed bits is increased.
Consequently, as long as the secret data is more protected,
the original signal will be more distorted.
In our experiments, each 10 sec ECG segment was 10,000
bytes (2500 samples x 4 bytes/sample= 10,000) and in each
sample we modified 1 bit to host the secret bits. Overall, we
could host 2500 bits = 312.5 bytes. As ECG host signal size
increases we are able to add more secret bits by replacing
existing bits of host data appropriately.
V. CONCLUSION AND FUTURE WORK
As a result of the large demand of sending and receiving
confidential information of patients in e-health care systems,
and the fact that ECG samples are large in size, they can be
used as hosts to carry confidential information as secret bits.
A new steganography technique is proposed to hide personal
information of patients inside ECG signals that are capable
of hiding the secret bits in any position of the digital signal
samples including the most significant bit. In this paper, it
has been proven that the proposed steganography technique
does not affect the significant features of the ECG signals
as the modifications performed on host signals in order to
secret data are not noticeable by naked eyes. The PRD of
modified watermarked ECG segments were very low for both
normal and abnormal ECGs. The proposed technique uses
very simple mathematical equations which can be easily
implemented inside the patient PDA device. On the other
hand, the receiver should know the signal pre-processing
parameters in addition to the selected special range as the
secret key to extract the embedded data. The validity of the
proposed technique has been proved by different simulated
attacks on the host signals. For future work, frequency
domain approaches will be proposed using discrete cosine
transform as a steganography technique that provide another
high level of security.
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[3] F. Hartung and B. Girod. Watermarking of uncompressed and com-
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