RFID-x

DEC 2012

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Ethical Concerns Challenges of RFID

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Radio Frequency ID What Is It?

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RFID Technology Social Responsibility

Healthcare Technology

RFID Radio Frequency Identification In Healthcare Industry

BY SHIRLEY A. BUGOSH

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Healthcare Technology

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Healthcare Technology

RFID Radio Frequency Identification In Healthcare Industry

By Shirley A. Bugosh, BSN, RN

As healthcare institutions struggle to balance the increasing need for their services with decreasing financial resources, they must look for efficient and cost effective means to manage delivery. Although not a new technology, radio-frequency identification (RFID) is recently demonstrating its potential in all sectors of industry, including healthcare. Implementation of RFID technology can improve effectiveness of health care delivery and increase patient outcomes, in considerations of cost containment, risk management, and utilization review. But ethical issues can impact its adoption, including concerns regarding access to personal information and privacy rights violation, as well as systems and process integrity.

Shirley A. Bugosh is a graduate student in Education Technology at Webster University. She obtained a Baccalaureate in Nursing Science at the University of Texas Health Science Center in Houston, Texas.

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Cost Containment Coordinating healthcare services often results in delays or inefficiencies of care delivery, straining the industry’s financial resources. For example, a facility can incur financial losses as a result of wasted time.

Daily challenges, particularly in larger hospitals, include locating patients or staff members in other areas of the facility or mobile assets like intravenous pumps and wheelchairs. One report noted nursing staff can “spend up to 30 minutes per shift tracking down equipment” (Turisco & Rhoads, 2008).

Financial losses can be attributed to unintentional incidents as well. For example, some surgical probes can cost thousands of dollars and accidentally be thrown out with medical waste or lost in soiled linens (Kumar, Livermont & McKewan, 2009).

Radio frequency identification (RFID) technology incorporated into employee badges and patient wristbands or placed on equipment can automate monitoring and tracking of these mobile assets.

Asset location is not the only challenge. Equipment maintenance is a crucial factor in providing equipment that is ready when needed. Portable devices such as IV pumps need charging and “surgical instruments and other devices must be properly cleaned, sterilized and packaged between uses” (Reiner & Sullivan, 2005). Recent RFID technology provides tags that can now withstand the steam sterilization processes (Kumar et al., 2009).

RFID’s potential contribution in hospital supplies management can also be seen in the replenishment systems. The automated data capture triggered by tags in real-time reports as new supplies are stocked or removed for patient treatments can “almost completely eliminate backorder situations . . . and eliminate counting stock” (Bendavid, Boeck & Philippe, 2010). Just as tags capture data of medical supplies in and out of replenishments systems, they can also keep track of resources used for patient billing purposes as well (Bendavid et al., 2010).

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Nursing staff can “spend up to 30 minutes per shift tracking down equipment” Turisco & Rhoads, (2008)

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Risk Management “Annually, an estimated 44,000 to 98,000 Americans die from medical errors” (Institute of Medicine, 2000). The complex process of inpatient medication management and administration involves multiple disciplines (e.g., pharmacists, nursing personnel, techs and physicians), providing many opportunities for errors to occur (Turisco & Rhoads, 2008).

A prime goal of healthcare industry is to decrease risk factors that can affect positive patient outcomes. The use of RFID technology in medication management can assist with this objective. For instance, RFID tags that have “read” and “write” capabilities provide a means where historical data or patient-specific safety information, like drug allergies and blood type, can be placed within the chip of medication labels and patient wristbands (Figarella, n.d.). Additionally, medication cabinets can be equipped with

RFID readers that capture real-time information, including removed, diminishing or expired stock and staff identification data (Bendavid et al., 2010). In combination with RFID patient cards, this information can be cross-referenced with pertinent patient-specific data such as correct dosage, drug interactions and allergies as well as billing data of items.

The “read” and “write” tags can also be used to monitor the “ped-

igree” of medications in concerns of pharmaceutical counterfeiting, where a medication’s life, from manufacture to administration can be traced. Estimates of counterfeit pharmaceuticals by the World Health Organization on average can range between 5 and 8 percent and can be as high as 25 to 40 percent in some countries, representing losses to the pharmaceutical industry of nearly $2 billion each year (Reiner & Sullivan, 2005).

“Annually, an estimated 44,000 to 98,000 Americans die from medical errors” Fisher & Monahan, (2008)

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Utilization Review Work flow management systems utilizing RFID can provide staff with real-time information, assisting in “prioritizing tasks, [as well as] recognizing and alleviating bottlenecks” (Turisco & Rhoads, 2008). Results are less time on phone calls to access the same information. In one study, “Nurses recouped up to one hour per shift by eliminating seven to ten phone calls and three to four workstation log-ins” (Turisco & Rhoads, 2008). RFID systems can also assist facility management in providing “more-balanced staffing” as real-time data reveals under and over staffed units (Turisco & Rhoads, 2008).

“Surgical errors are second only to medication errors as the most frequent cause of error-related deaths” (Institute of Medicine, 2000). In the surgical environment, RFID technology can increase outcomes by making read-

ily accessible the data necessary to complete surgical procedures.

For example, the synchronization of information (e.g., patient, staff and facility), supplies, and equipment can be integrated, allowing patient-specific analysis and evaluation (Egan & Sandberg, 2007).

One community-based health system in southwestern Pennsylvania is implementing a “suite of clinical access management and performance management solutions” that will provide “a single integrated technology backbone across its two hospital campuses and more than 70 community-based patient-care locations” (Heritage Valley Health System, 2011). Via “hand-held” devices, physicians can “quickly view . . . simply by touching their RFID equipped hand-held to any desktop computer” within the system (Heritage Valley Health System, 2011).

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“Surgical errors are second only to medication errors as the most frequent cause of errorrelated deaths” Institute of Medicine,( 2000)

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Healthcare Technology

ETHICAL CONCERNS RFID CHALLENGES Several chal-

lenges are related to recent interests in RFID technology in the healthcare industry. The economic crisis has forced institutions, including governmental agency such as Medicare and Medicaid to review spending through the scrutiny of such factors as resource waste, for example equipment loss or theft, reimbursements for unproductive or non-medical time, and additional service charges resulting from medical errors.

Noted in a report by Vilamovska (2010), “medication errors alone are estimated to harm 1.5 million Americans and to incur $3.5 billion in treatment costs each year”.

Also reported by the Institute of Medicine (2000), preventable medical errors “placed the cost of inadequate patient safety at 44,000 to 98,000 U.S. lives and at

least $17 billion in direct healthcare costs and productivity losses”.

In addition, new regulations and initiatives such as the American Recovery and Reinvestment Act (ARRA) and President Obama’s healthcare initiatives are “adding urgency to an already serious need to contain care cost growth and better the efficiency of healthcare delivery” (Vilamovska, 2010).

PRIVACY RIGHTS Although

RFID promises to assist with these urgent issues, several concerns have been expressed with the major one being privacy rights. In the article Tracking the Social Dimensions of RFID Systems in Hospitals, the authors write, “these systems may have a valence toward surveillance” resulting in a “panoptic effect” of self-policing that could extend “to enforce unequal social sorting

of individuals through profiling based on race, class, gender, and/ or sexual orientation” (Fisher & Monahan, 2008).

Privacy issues also include patient concerns in security of their personal medical information, for example, who will access it and how will it be used? In a keynote address of the 2011 Health Privacy Summit, Columbia University professor of Public Law, Dr. Alan F. Westin presented survey data that indicated, “health and financial information ranked most sensitive” in privacy concerns.

SYSTEMS & PROCESS Tech-

nology interoperability and integration within the healthcare institution is a complex issue.

The industry’s lack of common Ethical Concerns continued on page 9

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RFID What Is It ?

Tags are the heart of the system, storing information associated with the asset they track, which in most cases is a unique identification number. Tags include a memory chip and antennas and may be equipped with a power source. Their radio frequency of operation can include low, high, and ultra high frequency radio waves or microwaves.

Having a discoverable range from several millimeters to a far as 12 meters, passive tags have no built-in battery source. These

tags rely on the reader’s power to activate the transmission of their data.

The most frequently used RFID tags in hospitals include active and hybrid - semi-passive types. Active tags contain battery sources that boost their signals, which can be transmitted as far a far away as 100 meters.

Active as well as hybrid tags can be equipped with sensors that can relay data regarding their environment like temperature or pressure.

“RFID is not merely a computer chip and antenna placed on a product, but rather it is an entire infrastructure that requires investment in many components and systems to make it work.

This includes hardware, middleware and software components.”

Health Industry Business Communications Council

TAGS Active tags can use wireless local area network systems and Wi-Fi to connect to middleware. Additionally, some tags have the capability of not only storing a unique identifier number but can store additional information, for example, drug allergy information and blood type stored on patient wristbands.

READERS Readers can be portable, including hand-held readers and mobile data collection devices, or they can be fixed readers where tagged assets are read as they pass through or near the device. Readers use antennas to capture radio waves from tags and transmit this information back to middleware systems for processing.

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MIDDLEWARE The system that receives the data from readers is called the middleware. This system is responsible for collecting the raw data from the tags and making sense of it. Examples include the event management of patient and staff work-flow and real-time alerts like medication cabinet access.

This software also communicates with the host system or the facility’s main information system.

Healthcare Technology

. . . Ethical Concerns continued from page 7

standards of tags and readers results in the inability of communications between proprietary systems. Intellectual property patents of RFID systems are held by technology companies that can be from anywhere in the world, resulting in differences of chip design, middleware programing code as well as radio frequencies (Kikirekov & Oehlmann, n. d.). Integration issues also arise between emerging technologies and existing host systems, often written in legacy code (Egan & Sandberg, 2007).

The significance of these issues is institutions buying into proprietary systems may limit their potential for financial and management gains offered by implementing RFID technology. As expressed in one report, “different Auto-ID technologies best serve different purposes, an organization seeking to deploy Auto-ID technology might well find itself using a number of vendors, each with a standalone system” (Egan & Sandberg, 2007).

HOST SYSTEM In healthcare, the host system is known as health information system (HIS). It is the complex system that manages the storage, retrieval, sharing, and use of information throughout a healthcare institution.

Noise interference in competing air space of essential medical equipment presents challenges as well (Egan & Sandberg, 2007).

For example in a research study looking at electromagnetic interference of RFID and its effect on critical care equipment such as infusion syringe pumps, external pacemakers and mechanical ventilation, demonstrated potential hazards and a need for further studies (van der Togt, van Lieshout, Hensbroek, Beinat, Binnekade & Bakker, 2008).

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SOCIAL RESPONSIBILITY Healthcare presents with unique and complex environments “full of tightly coupled, hard-to-see systems” that can make RFID implementation difficult (Berwick, 2008). To make RFID implementation successful., several major issues must be addressed.

PRIVACY A range of concerns

regarding RFID technology have been expressed, from a “misunderstanding” of what the technology is, to an extreme “portrayal of a tool for Orwellian Big Brother observation of private lives and activities” (Vilamovska, 2010).

Additionally, in a study on social dimensions of RFID in hospitals, nurses expressed concerns of “being overly scrutinized by these tracking technologies” in which the “systems are based upon rational management models that do not accurately match the messy realities of hospitals” (Fisher & Monahan, 2008).

Responsibility of hospital administration is to ensure that patients and staff members have an understanding of RFID technology.

Educational opportunities should provide information about what data will be stored on RFID tags, how it will be used and who will have access to it. In addition, this information should be put into institutional policy and reviewed frequently as RFID technology advances and as its use changes.

STANDARDS The lack of RFID

industry standards presents a challenge in the healthcare industry’s concerns of compliance with “privacy protection mandated under HIPAA (Health Insurance

Portability and Accountability Act of 1996)” (Fisher & Monahan, 2008). Additionally, meshing the radio frequency technology with the many technical devices within the hospital’s environment is a daunting task.

As Berwick (2008), stated, “design in isolation is risky”. Creators and manufacturers of RFID technology must develop design teams that include stakeholders of the healthcare industry with end-users included. Additionally, design must accommodate the complex needs of the healthcare environment.

“High-quality empirical data on the quality and cost RESEARCH Policy makers and of healthcare RFID healthcare administrators need to applications are make informed decisions regarding return on investment and scarce” relevance of use in choosing to adopt new technology like RFID. Noted by Vilamovska (2010), “High-quality empirical data on the quality and cost of healthcare RFID applications are scarce” as are studies that reflect its impact on the “people-ware” involved in its use (Fisher & Monahan, 2008).

We must promote research that documents outcomes of RFID application and best practices in specific uses, to provide evidence that can back-up decisions made by those responsible for the decision-making process.

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Fisher & Monahan, (2008)

Healthcare Technology

RFID TIME LINE 1940’s

Radar is refined and used in major World War II development effort.

The first RFID application was the “Identification Friend or Foe” system - IFF or transponders. Invented in 1948, these IFFs were placed into fighter planes and tanks. Successors of this technology are still used in armies around the world today.

1970’s

The 1970’s were characterized by developmental work in radar and microwave theory. Advancements lead to the totally passive tag with detectable ranges of up to several meters. Animal tracking, mostly in Europe, and vehicle tracking, and factory automation in the United States became the focus of intended uses.

1980’s

The 1980s became the decade for full implementation of RFID technology, with differing interest throughout various parts of the world. In the United States, studies of RFID uses primarily focused on transportation, with greatest interest in toll collection. Advancements in circuitry design contributes to reduction in size, as well as increases in functionality of tags.

1990’s

The 1990’s was a significant decade for RFID because of wide scale deployment of electronic toll collection in the United States. In the Northeastern United States, seven regional toll agencies formed the E-Z Pass Interagency Group (IAG) in 1990 to develop a regionally compatible electronic toll collection system. This system is the model for using a single tag and single billing account per vehicle to access highways of several toll authorities.

2000’s

Since 2006, RFID tags included in new US passports have stored the same information that is printed within the passport and also has included a digital picture of the owner. In October 2004, the FDA approved USA’s first RFID chips that can be implanted in humans. The emergence of standards, decreased cost of equipment and tags, and increased reliability of 99.9% provide incentive for widespread adoption.

Source: Landt, J. (2005, October/November). The history of RFID. IEEE Potentials, 8-11.

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References Bendavid, Y., Boeck, H., & Philippe, R. (2010). Redesigning the replenishment process of medical supplies in hospitals with RFID. Business Process Management Journal, 16(6), 991-1013.

Berwick, D. M. (2008). Taming the technology beast. Journal of the American Medical Association, 299(24), 2898-2899.

Egan, M. T., & Sandberg, W. S. (2007, March). Auto identification technology and its impact on patient safety in the operating room of the future. Surgical Innovation 14(1) 41-50.

Figarella, L. (n.d.). Radio frequency identification (RFID) in healthcare: Benefits, limitations, recommendations [Whitepaper]. USA: Health Industry Business Communications Council.

Fisher, J. A., & Monahan, T. (2008). Tracking the social dimensions of RFID systems in hospitals. International Journal of Medical Informatics, 77(2008), 176-183. Retrieved on November 27, 2011 from: http:// torinmonahan.com/papers/Fisher_Monahan_RFID_IJMI.pdf Heritage Valley Health System. (2011, August 01). Heritage Valley Health System selects the Sunrise acute care electronic health record from Allscripts [Press release]. Retrieved on November 29, 2011 from: http:// www.heritagevalley.org/Media/Releases/2011-29A.aspx Institute of Medicine (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.

Kikirekov, K., Oehlmann, H. (n. d.). Radio frequency identification (RFID) in healthcare: Benefits, limitations, recommendations (Whitepaper]. Health Industry Business Communications Council. Retrieved on November 27, 2011 from: http://www.hibcc.org/PUBS/WhitePapers/RFID%20in%20Healthcare.pdf Kumar, S., Livermont, G., & McKewan, G. (2009). Stage implementation of RFID in hospitals. Technology and Health Care 18(2010) 31-46.

Reiner, J. & Sullivan, M. (2005). RFID in healthcare: A panacea for the regulations and issues affecting the industry? [Whitepaper]. USA: United Parcel Services of America, Inc. Turisco, F., & Rhoads, J. (2008, January). Equipped for efficiency: Improving nursing care through technology [PDF document]. Oakland, CA: California Healthcare Foundation. van der Togt, R., van Lieshout, E. J., Hensbroek, R., Beinat, E, Binnekade, J. M., & Bakker, P. J. M. (2008, June 25). Electromagnetic interference from radio frequency identification: Inducing potentially hazardous incidents in critical care medical equipment. Journal of the American Medical Association, 299(24), 2884-2890.

Vilamovska, A. (2010). Improving the quality and cost of healthcare delivery: The potential of radio frequency identification (RFID) technology. (Doctoral dissertation). Retrieved on November 20, 2011 from Rand Corporation at: http://www.rand.org/content/dam/rand/pubs/rgs_dissertations/2010/RAND_ RGSD239.pdf Westin, A. F. (2011, June 13). What two decades of surveys tells us about privacy and HIT today [Video presentation]. Keynote address presented at 2011 Health Privacy Summit. Washington, DC: Health Privacy Summit. Retrieved on November 22, 2011 from: http://www.healthprivacysummit.org/videos/session-1keynote-speaker-dr-alan-westin Radio Frequency Identification: In Healthcare Industry Š 2012 Shirley A. Bugosh