Next-generation tracking

Sept. 23, 2014

Location may drive valuation and worth in the real estate world, but within a healthcare organization it can determine return on investment as well as affect revenues and expenses.

In a reform-minded industry, healthcare facilities need the tools and wherewithal to track their product- and service-related assets, including staff members, the patients they treat, the processes for which patients undergo treatment, and the devices and equipment used in the treatment of patients and in running the organization.

With satisfaction surveys contributing to reimbursement qualifications, healthcare organizations must track patient migration through their processes as well as how staffers interact with them. For utilization and value analysis, healthcare organizations also must know which products and processes are being used in the delivery of care as well as how to keep track of their whereabouts and replenish them with limited interruptions in service.

Put together, all of this affects the bottom and top lines of the balance sheet. And for a growing number of healthcare organizations, these efforts call for more than paper records and barcode capabilities.

Now 14 years deep into the 21st century, healthcare information technology executives and professionals have witnessed the ballooning of technology options to facilitate financial and operational management. From desktop personal computers to laptops, notebooks, tablets and smartphones to wired and near-ubiquitous wireless access, the gamut of hardware and software choices geared to track all of the stuff and people moving throughout their facilities is plentiful. Further, they have kept pace with tracking capability migration from barcoding advancements to radio frequency identification (RFID) and real-time location systems (RTLS) that can employ infrared, ultraviolet and other “modalities” for key tasks.

But as healthcare reform regulations, reimbursement cutbacks and annual budget cuts motivate IT executives and professionals to think carefully about what tracking technology to evaluate and implement, Health Management Technology opted to explore how healthcare organizations pinpoint the technology needed for managing their assets, including how they evaluate RTLS, RFID and other options.

HMT: If you were trying to determine whether to invest in and deploy some type of real-time location system (RTLS) technology to track your organization’s assets, what financial and operational factors would you have to consider?

Jon Poshywak, Vice President and General Manager, TeleTracking Technologies

Poshywak: With everything on the horizon or coming online now, such as operational management platforms, the first question should be, “Can this system integrate with automated patient logistics software and other systems?” Buying an RTLS system that only tracks assets is buying yesterday’s technology.

Barry Cobbley, Director of Sales Engineering, Versus Technology

Cobbley: Accuracy. Make sure you inquire about location accuracy. Don’t just talk to the vendor. Also spend time with their customers. Will the system point you to an asset’s general location, or to a specific room? Does the signaling technology bleed through walls and ceilings, causing possibly false location reports? Each vendor in the marketplace achieves real-time locating through different methods. Some of these methods offer more accuracy than others. While your staff will like an RTLS that narrows their search for equipment, they will truly appreciate a system that eliminates searching altogether.

Capability to expand beyond assets. A good RTLS can do much more than track equipment. If your hospital might ever want to build on the asset tracking foundation to automate nurse call, patient workflows, hand-hygiene monitoring, bed management or interface with your EMR, be sure the vendor you choose offers the accuracy needed and has experience with these applications.

Ease of use. The RTLS has to be intuitive. Make sure the displays are not difficult to interpret. In addition to Biomed staff, any nurse should be able to locate equipment he or she needs. For the highest ease of use, invest in a system that offers par-level asset management. Our clients using RTLS to monitor asset inventories tell us that nursing staff rarely have to use the system. Thanks to the alerts that inform the proper personnel when inventory is low, equipment is always clean and available for patient care. It doesn’t get easier than that.

Do you already have RTLS? Check to see if you already have an RTLS foundation in place. Many hospitals have automated nurse-call systems (where staff wear badges that automatically record their presence in the patient room to cancel a call), but don’t realize this same network can be utilized for asset tracking and other applications.

Total cost of ownership. Some hospitals start with a less accurate system, then add hardware as their need for room-level accuracy increases. The total cost of this strategy can be significantly higher than investing in accuracy at the outset. Consider battery life for not only tags, but (if you’re considering a wireless system) also sensors. How often will you need to change batteries, and how much labor will be required? How do you plan to dispose of the used batteries? These factors can significantly add to the total cost of a system. Versus offers both wired and wireless sensors; even though our wireless sensors have excellent battery life using standard D-cells, it’s interesting that recently we’ve seen a shift with some healthcare facilities not wanting to bother with batteries at all, instead opting for the wired solution.

Data. Of the many benefits of RTLS, a significant one is amount of data collected, metrics that can be used for process improvement. Is this data accurate and readily available? Is there a mechanism in place to help you analyze it? In an asset tracking example, is there reporting in place to help you determine how often assets are used? Where they’re most often used?

ROI. Determine what kind of return on investment you want to see and how you plan to measure it. Be sure you have baseline data. For example, if you want to increase IV pump utilization, determine your existing utilization rate, then measure again after implementing RTLS to determine ROI. Your RTLS vendor should be able and willing to help you determine baseline data.

Adam Peck, Director of Marketing, CenTrak

Peck: To determine the feasibility that an RTLS deployment will deliver substantial benefit to an organization, CenTrak recommends considering the following factors:

Step 1: Identify use-case requirements by forming an evaluation committee consisting of: Biomed, IT, Nursing, C-level executives, Surgical Services, ED, Patient Safety, Risk Management, Security and Infection Prevention.

Step 2: Agree upon specifications. Ensure that there is a common understanding and definition of various accuracy levels (room-, bed-, bay-, chair-level). Also make certain that all battery-life expectations are clearly documented with detailed assumptions related to the activity level for each tag and infrastructure update speeds.

Step 3: Focus on integration and scalability. Identify the role that the existing Wi-Fi network will play in the deployment. Examine the capabilities of the technologies currently owned and expose gaps that may require the acquisition of niche RTLS application functionality. Project the number of tags in future states and ensure that the recommended architecture will be capable of supporting the targeted use cases well into the future.

Matt Perkins, Chief Technical Officer, Awarepoint

Perkins: First and foremost, it’s important to understand that RTLS is capable of doing much more than locating tagged items or people. It can be used to reduce care delays, improve hand-off communication, simplify care coordination, expedite room turnover, reduce patient wait times and simplify overall caregiver workflow. Many organizations realize that they want more functionality from their RTLS system after they’ve already invested in an infrastructure, and then it’s very difficult to go back to leadership with another budget request.

One important question to ask is whether the system has the ability to affect major change in an organization’s workflow. The selection criteria are quite different for a “where’s my stuff” solution versus an extensible RTLS platform that supports true asset management and utilization, patient flow, caregiver efficiency and satisfaction. Significant differences include location accuracy requirements, the need to integrate with other HIT systems, complex workflow interpretation and management, and the data and analytics to support process-improvement initiatives. Organizations must invest in a flexible RTLS solution that can meet their evolving needs.

Leaders should look beyond the immediate need for an RTLS and consider what their constituents will be asking for in the next 12 to 36 months. They need to ensure that the system has the ability to grow. In the end, they’re going to be happier with the system’s performance because the more advanced patient and staff applications will, in fact, require more sophistication and flexibility on the hardware, software and integration.

Joel Cook, Senior Director of Healthcare Solutions, Stanley Healthcare

Cook: From the beginning, plan to scale using your existing infrastructure or platform. Our customers have had great success deploying modular systems that work using their facilities’ existing Wi-Fi infrastructures, then continuing to add applications based on new needs. Building on a single platform makes initial implementation and ongoing updates less expensive and quicker.

Even if healthcare organizations are deploying systems for one department and one application today, it’s best for them to choose a system that is scalable and extendable with new uses like asset tracking, environmental monitoring, workflow management and others. As we’ve seen, hospitals will often begin with RTLS programs for asset management and equipment maintenance, and once those basic business problems are addressed they will use these same infrastructures to add patient and staff safety, workflow optimization and condition monitoring capabilities.

HMT: What are some of the practical differences between the various RTLS modalities, in terms of equipment needed?

Poshywak: The main differences between the major active RTLS technologies in the market today are the way the systems communicate and the way they locate. The two primary communication (backhaul) methods are Wi-Fi and 900 MHz (RF). This is the manner in which data is communicated back to a location server or infrastructure appliance, and then to an application server. Location methods vary. The primary methods are Wi-Fi triangulation, IR (Gen2IR, direct line of site, etc.), Ultrasound, and Low Frequency. There are pros and cons in using each technology, primarily related to speed, accuracy and cost. 

Cobbley: The biggest difference between technologies is how badges and tags communicate with the RTLS. With the Versus system, badges and tags emit both infrared and RFID signals, which offers the highest degree of accuracy. Because radio frequency (as well as Wi-Fi) travels through walls and ceilings, it’s not accurate enough to offer room-level location. However, it’s very useful for providing general location and communications. The proprietary infrared portion of our system is bound by the same rules as visible light – IR bounces around a room, but it is contained. By putting a single infrared sensor in each room, or one sensor over each care location in the same room, we can determine location down to a very granular level. Other RTLS vendors trying to achieve similar levels of accuracy (room-, bed-level) have to install additional technology, resulting in more hardware components and increased costs.  

Peck: RTLS solutions are comprised of several components including infrastructure (e.g., wireless room-level devices) and tags, RF backbones (e.g., Wi-Fi) and servers. RF backbones are useful only for the transmission of information and zone-level locating or “dots on a map” use cases (e.g., asset tracking).

Workflow use cases require the precision and rapid update speeds that can only be offered by technologies like Second Generation Infrared (Gen2IR), ultrasound and low frequency. Gen2IR and ultrasound operate similarly. They are both resistant to the line-of-sight constraints that have plagued legacy infrared technologies, but Gen2IR technologies can be fully waterproofed – an increasingly important requirement for asset and patient tracking deployments where infection control is a concern. Low-frequency technologies are required for security applications (assets, patients, infants) where tags may intentionally be hidden to escape detection or movement. A low-frequency exciter creates a “bubble” around an egress area that fully penetrates to ensure that any tag passing through the area is detected.

Perkins: All modalities, either individually or used in combination, are capable of delivering the location accuracy required of a variety of use cases. However, not all RTLS solutions are capable of taking you beyond asset location. If you purchase an RTLS solution that lacks sophistication in automating workflow, then you have to consider the cost of adding additional technology and infrastructure down the road. The biggest mistake that people make is forcing RTLS use cases onto an existing data-transfer infrastructure, as these networks weren’t designed for location accuracy, and yet accuracy is critical in driving patient care activities.

Buyers should evaluate the total cost of ownership for delivering a 36-month roadmap. Deploying the right infrastructure to support your holistic needs will actually cost less than if you buy a sub-standard system that only finds things but has to be enhanced or replaced later. Organizations should also talk with other healthcare leaders that have already adopted these solutions to understand how they designed their roadmap, which will be helpful when planning your own strategies.

Cook: Because Wi-Fi is now common in healthcare facilities, the major benefit of Wi-Fi RTLS is that it leverages an organization’s existing wireless infrastructure. This speeds up deployment and reduces installation and operating costs. Healthcare organizations can then build upon their Wi-Fi RTLS for evolving needs and uses. A significant advantage of leveraging the Wi-Fi infrastructure is that items and people may be located enterprise-wide from the first day.

RTLS consists of active RFID tags that come in a variety of form factors and different features. These systems can calculate the updated location of the tag, show this on a graphical user interface and be integrated with other hospital management systems. Healthcare organizations often add supplemental components to their RTLS to provide higher levels of spatial resolution for features such as room-level specificity. This is important as facilities seek real-time insight into the safety, security and movement patterns of individual patients, residents and staffers. 

Stanley Healthcare uses a combination of ultrasound and low frequency to provide the room and choke-point specificity when the use case merits higher resolution. Ultrasound is ideal for room-level resolution (e.g., for patient flow, nurse call and hand-hygiene compliance monitoring). It does not go through walls or glass and is not impacted by bright light, as infrared can be. Low frequency, on the other hand, is useful for choke points, directional flows and for bay-level location in clinic treatment chairs, PACUs and ED bays. Our solutions use Wi-Fi as the core location technology, providing at least zonal resolution in all cases.

HMT: For which applications does RTLS and varying options make the most sense to apply?

Poshywak: All of the above, because when combined with the right software, RTLS can provide an online “motion picture” of virtually all hospital functions so managers can keep tabs on daily task performance, census, etc. For example, RTLS is the enabling technology that drives TeleTracking’s entire automated operational management platform. 

Cobbley: The smart course of action is to choose an RTLS that can handle all these applications – and handle them well. This allows you to start with more foundational uses like asset tracking or nurse-call integration, then in the future leverage the same RTLS network for more advanced uses, such as patient workflow or bed management. Otherwise, you may be faced with a second round of installing expensive hardware, or even investing in a different RTLS. 

Peck: Every facility has its unique array of pain points, and no individual RTLS solution is likely to address each of them with equal effectiveness and efficiency. There is a hierarchy of locating needs, proceeding from zone-level locating and presence detection for use with assets and environmental monitoring (most often achieved with an RF-only technology – e.g., Wi-Fi), to locating the current status of patients and staff in and out of clinical zones, to communications that deliver information about the status of a tag to the right people, and finally to workflow enhancement where true process improvements can be facilitated. In general, the more precision the use case requires, the more likely a certainty-based technology (e.g., Gen2IR) will need to be utilized.

Perkins: Tracking assets is the most recognized use case for RTLS. Assets must be tracked enterprise-wide and be accurate at room level. Assets cannot go “off grid” as they move into small closets, basements and other out-of-the-way locations on campus. Some RTLS solutions allow tags to be hidden and/or signals to be blocked, which encourages equipment hoarding in cabinets and other storage spaces and reduces overall utilization rates (requires more inventory). Other solutions fail to provide the accuracy needed to efficiently automate asset movement across the organization, which reduces staff efficiency and fails to detect policy breaches (e.g., bypassing the Central Supply cleaning procedure between patients).

There are three key questions to keep in mind when considering various RTLS modalities. First, will the technology be able to penetrate obstructions like blankets or cabinets? Second, can the technology deliver the accuracy required across the entire enterprise, while still being cost effective? And third, is the technology room-level and bay-level accurate, in order to track patients and staff, for maximum impact and efficiency? Buyers must recognize that they will be asked to build upon their RTLS system almost immediately after basic locating functionality is installed; they are wise to invest time in understanding the full potential of RTLS before they make a purchase decision.

Cook: Wi-Fi-based RTLS is ideal for a wide range of applications, from asset management to staff and patient safety, and security to staff workflow and patient flow. What makes
Wi-Fi RTLS particularly well suited for these applications
vs. other modalities is that it provides facility-wide or campus-wide visibility.

Healthcare organizations typically first deploy Wi-Fi RTLS to monitor and manage assets with the goal of improving efficiency and productivity. Then, based on the significant benefits they realize as a result of the first application, they extend it to additional departments or to include additional use cases such as environmental monitoring and patient/staff tracking.

Monitoring staff or patient safety and security are other common uses of Wi-Fi RTLS. Emergency departments, psychiatric departments, memory care facilities and assisted-living facilities all include high-security areas where it is important to monitor staff in duress or patients or residents in need of assistance. At the room level, hospitals can also track staff workflow as well as hand-hygiene practices of clinicians and staff. Wander management is an example of how RTLS can be used to precisely monitor patient location and offer residents assistance as needed.

HMT: What are some of the key issues that must be considered when choosing RTLS software to interface or integrate data with existing back-end systems?

Poshywak: The biggest issues here are related to project implementation. Integration and interfaces must be properly identified and scoped during the pre-sales activity of an RTLS project. The ability to interface to CMMS databases, EMRs, ERPs, etc. is critical to the long-term success of an RTLS deployment as it eliminated redundant data input, and even more importantly, significantly reduced the opportunity for database corruption. Establishing single-direction or bi-directional interfaces allows different groups to maintain current processes in existing applications while optimizing the effectiveness of an RTLS deployment.  

Cobbley: First, you must ask if the RTLS hardware produces accurate location data that is error-free and meaningful to downstream systems. With that assumption vetted, then your middleware must be able to filter and manage the data in such a way to provide it in a readily consumable format to the systems that need it. 

Peck: The most important consideration when choosing an RTLS to integrate with existing hospital applications is the performance of the underlying infrastructure and tags. The old “garbage in, garbage out” maxim applies. There are already RTLS integration specifications that make the transfer of information easy. But if the RTLS is not capable of providing true Clinical-Grade Locating (accuracy, speed, power efficiency), the integration will not be effective and the associated project will fail.  

Perkins: Automating workflows in a clinical setting requires more than just location information. Streamlining patient flow and caregiver efficiency requires the ability to integrate with other health IT systems in order to know when patients were admitted, how long they have been waiting, whether the labs that were ordered have been drawn yet or if the radiology technician has been at the bedside. To avoid limiting your RTLS to a “Where’s Waldo?” type of application, it’s critical to interface with clinical systems and provide context around the patient’s plan of care and the activities of your staff members. 

Your RTLS software platform is by far the most important aspect of successful adoption of RTLS technology. You need a platform that allows you to automate complex workflows with a workflow engine – a critical component of RTLS technology that will help you to realize the outcomes defined in your 36-month roadmap.

Cook: Ease of use should be a top priority. Anytime you introduce new technology to a healthcare environment, it needs to be intuitive for people to use and it needs to be easily accessible to users based on their role. Different teams and roles should have different access levels. Nurses and housekeepers should have different access levels, for example. Staff and clinicians should be able to intuitively access the information they specifically need, when they need it and even how they need it. Information must be accessible on all types of devices, from wall-mounted displays to tablets to mobile devices.

New systems should also have open APIs and be able to accept information and communicate with third-party systems, support various standards like HL-7 and be easily integrated with business intelligence software. Hospitals should be able to give staff actionable information via their RTLS, so that they can monitor exactly what is happening in the facility and quickly take action. The RTLS will often be transparent to clinical users, driving information into the other systems that they use, such as EMRs, ADT, infusion-pump management software and CMMS. A sophisticated RTLS platform, such as Stanley Healthcare’s MobileView, will be able to broker information between all of these types of systems and provide enhanced value to them and their end users.

Forward thinking: Tagging assets in 2020

What do five RTLS executives foresee about their tagging technology’s reach and utility six years from now? 

Jon Poshywak, Vice President and General Manager,
TeleTracking Technologies

RTLS is the technology that will drive the automation of all hospital processes that support the delivery of care. It will be key to bending the healthcare cost curve through the removal of wasted time and resources and the contribution of new revenue to hospital margins. 

Barry Cobbley, Director of Sales Engineering, Versus Technology

We are already seeing a continued increase in not only the number of healthcare organizations implementing RTLS, but also in the use of the technology in more meaningful ways. There’s an increasing level of education in the marketplace about what RTLS can do – a realization that it’s more than basic locating, it’s workflow management and process improvement. Hospitals are now, and will continue, [moving] beyond asset tracking and use RTLS to monitor and manage complex workflows. 

Also, the technology is expanding into different areas of healthcare. Not only hospitals, but outpatient clinics, primary care and eye care practices, just to name a few, are implementing RTLS to help with process improvement. RTLS is helping improve patient flow, giving these practices the ability to increase patient volume and provide more access to care. With millions of new patients entering the front doors of physician offices and emergency departments as a result of the Affordable Care Act, healthcare must turn to efficiency tools like RTLS. As we approach 2020, this type of RTLS use will move from the bleeding edge to the mainstream.

Adam Peck, Director of Marketing, CenTrak

As RTLS matures from addressing simple asset tracking use cases to a clinical visibility infrastructure, new applications utilizing location awareness will be woven into operations. In the future, RTLS will support the orchestration of care throughout the clinical enterprise. It will streamline processes, make more efficient use of scarce resources (both human and capital), will improve clinical quality while reducing preventable errors, and will integrate with existing information systems to share data across a wider range of users. 

Matt Perkins, Chief Technical Officer, Awarepoint

Today, the industry is so focused on debating the merits of various technology approaches that it’s largely missing the point. The key consideration should be evaluating RTLS platforms that can grow as different technologies are invented or realized. The healthcare community really hasn’t embraced RTLS beyond basic locating and tracking, but a few organizations are impacting a wide range of operational efficiency and customer satisfaction goals. I believe the power of this technology in the future has great potential to positively impact many components of patient and family satisfaction with its ability to create a seamless patient experience.

It is absolutely critical to choose a platform that can grow with new technology developments and new requirements, especially when considering integration with other health systems. You will need to incorporate lots of different technologies, whether they be ZigBee, Bluetooth low energy or traditional RFID — passive or active — because there is no one-size-fits-all solution. In the next five years, the RTLS platforms that cannot accommodate those various inputs are not going to meet the needs of the end users and will ultimately filter themselves out of the market. I envision a future where intelligent RTLS technology converges to address a wide range of commercial clinical need and personal and family needs through location-driven, context awareness.

Joel Cook, Senior Director of Healthcare Solutions, Stanley Healthcare

The most exciting part about the future of RTLS really goes beyond the technology — it’s about how extensively empowered healthcare professionals are going to become. The business intelligence and predictive analytics capabilities associated with RTLS will open entirely new windows of visibility within healthcare organizations, providing them a level of knowledge and insight that’s never been accessible before. Productivity and efficiency is just the starting point. By having both real-time and historical information about the movement, status and conditions that are occurring 24/7 throughout the facility, we’re going to see significant advancements in the quality of care by enabling healthcare professionals to predict conditions before they ever occur – thereby permitting them to focus on patient care, better clinical and financial outcomes and enhanced patient experience and staff satisfaction.