EXECUTIVE SUMMARY
Barcodes are a proven technology for reducing medication administration errors, while RFID tags show promise for tracking of assets as well as personnel and patients. Yet implementation has been slow, as hospitals struggle with cost and complexity issues.
Hospitals are an ideal environment for barcodes and radio-frequency identification (RFID) tags, where they have been applied successfully in a number of applications. As many hospitals have demonstrated, the use of barcoding, when combined with patient-safety best practices, is a proven, and relatively inexpensive, preventative measure to prevent medication administration errors at the point of care. RFID, while earlier in the curve than barcodes, has shown promise in asset tracking.
But implementation of both technologies in healthcare has been relatively slow, as hospitals deal with budgetary issues as well as those of complexity. As noted by Jared Rhoads, senior research analyst for emerging practices at the Falls Church, Va.-based CSC, competing demands on hospitals faced with complaining with meaningful use could continue to hobble the uptake of promising tracking technologies.
One of the interesting possibilities in the implementation of barcoding-facilitated medication administration is that the barcodes can be linked to a decision support system, according to Rhoads. It can check to see if the medication is appropriate to someone of that weight, and if the patient's weight is stored in the system, you can do checking that adds more value, he says.
THE RIGHT MEDICATIONS
Nonetheless, some experts say the technologies bear looking into, particularly in the area of medication administration. One proponent is Mark Neuenschwander, president of The Neuenschwander Company, a Bellevue, Wash. consultancy, and an expert in drug dispensing automation and point-of-care barcoding systems. He has been an active supporter of the use of barcodes in patient safety for nearly 20 years.
Neuenschwander notes that barcodes are a key way to ensure proper patient identification at the bedside. “Barcodes do not replace human interaction with the patient,” he says, “but they are a redundant identifier that is more fail-safe than any other approach,” he says.
He estimates that 35 percent of hospitals in the U.S. now scan medications at the point of care, up from 3 percent of hospitals doing so in 2001. This is a significant increase, but still far from pervasive, he says. In other applications, the use of barcodes has been spotty. Neuenschwander estimates that less than one-third of hospitals use barcodes in transfusions. And while barcodes are used to track specimens in labs, they are not necessarily used to scan at each step in the entire process, from the time the sample is taken from the patient, he says. “Everything starts with knowing who you are with, the right patient,” he says.
Over the last 10 years, considerable groundwork has been laid for the use of barcodes on medications, according to Neuenschwander, setting the stage for wider use of barcodes at the point of care. He estimates that only 30 to 35 percent of medication packages had barcodes in 2001. At the time, he says, hospitals were open to the use of barcodes, but most medications still lacked them, and vendors and drug manufacturers saw little motivation to put barcodes on products because there was little scanning activity by hospitals. In 2004 the Food and Drug Administration (FDA) broke the logjam by requiring barcodes on human drugs and biological products. Today, virtually all medications at the point of care have barcodes, he says.
Neuenschwander is careful to make the distinction that the FDA mandate for barcodes on drug packaging is not a requirement for its use at the bedside. “There's pushback,” he says. “Everybody might believe in it, but nobody feels like hospitals should be forced to do it. Hospitals are already suffering from costs.” He believes that, more likely, barcodes increasingly will be viewed as a de facto best practice. “It will be self-imposed, not regulated,” he says.
Interestingly, Neuenschwander says, barcodes per se are not mentioned under meaningful use, although seven of 15 measures of first round meaningful use requirements include medication reporting in the electronic medical record (EMR). As an example of the gaps that still exist, he notes that it is possible to use electronic medication administration record (eMAR) without barcoding, and enter the medication administration information on a computer that is not at the point of care.
“We believe that the point of verification and the point of documentation should be at the point of care, not down the hall on a computer,” he says. He advocates scanning the barcode on the medication and the patient, entering that information in real time into the eMAR at the point of care to eliminate gaps where errors can occur.
WE ARE AGGRESSIVELY LOOKING AT NEW AND EVOLVING TECHNOLOGIES; WE ARE MUCH MORE CONSERVATIVE ON THE DEPLOYMENT.-PAUL FRISCH, ph.d.
Neuschwander is hopeful that terms such as closed loop-closing the entire medication administration loop with technology-and even the term barcoding, will be included in the next round of meaningful use requirements.
TRACKING ASSETS
RFID has made inroads in asset tracking in hospitals, both in the active RFID, in which the tag uses a battery to power its circuitry and antenna; and passive RFID, in which the tag contains no battery, and is powered by a reader. One hospital that has deployed RFID and is in the process of researching potential applications is Memorial Sloan-Kettering Cancer Center in New York.
The deployments that Sloan-Kettering has made with RFID devices demonstrate the various tradeoffs that need to be considered when deciding which technology to implement. One concern of Paul Frisch, Ph.D., assistant attending, department of medical physics and chief, biomedical physics and engineering, is the risk of stratification if technologies are implemented without a unified strategy, which could be costly in terms of dollars and workload, he says.
So far, Sloan-Kettering's experience has primarily been with active RFID technology, used for asset inventory applications. It rolled out its first active RFID application in January 2007, which was associated with the hospital's financial auditing process. “As a research institution, we do a significant amount of funding. And there are various audits associated with these grants. We use RFID to audit all of the hardware purchases associated with these grants,” he explains.
The RFID tags are integrated with the hospital's extensive WiFi backbone, which extends throughout the hospital and research center. It has since expanded its asset tracking, using active RFID to locate wheelchairs and stretchers for escorting patients, as well as all of the hospital's infusion pumps. With the infusion pumps, the RFID tags are used for both asset tracking and workflow, by providing information about their location, as well as whether they are in use or not.
Active RFID tags are also being implemented for tracking staff, replacing an infrared (IR) tags that have been integrated with the hospital's nurse call system. Using the RFID tags will allow the hospital to precisely locate the clinician, as well as do various device integrations, Frisch says.
One of the advantages of active RFID technology is that it allows the collection of data, such as response times, that can be applied to various metrics.
One of the deciding factors in choosing the appropriate technology is the hospital's infrastructure itself. In Sloan-Kettering's case, active RFID made sense, because it could be integrated with the hospital's existing WiFi infrastructure. Passive RFID would require installing a separate infrastructure, Frisch says. Neither solution is inexpensive, he says. “It comes down to your ultimate number of tags and also has to do with the application and what you are trying to achieve,” he says.
In general, Frisch says, active RFID tags are attractive for asset tracking in institutions with a large footprint. Passive RFID tags enable tracking on a localized scale. Many institutions can benefit by a combination of both technologies, he says. The trick becomes how to merge the two so they are transparent to the user, and also so the two systems share information as much as possible, he says.
Most of the work Sloan-Kettering is doing with passive RFID is investigational. Its only actual implementation of embedded passive tags is to track and count surgical sponges.
It is also investigating the use of passive RFID tags to track certain surgical devices have gone through the washing process, as well as the use of passive tags to make sure surgical kits are complete before going into service. One potential problem is that surgical instruments are metal; and placing tags on instruments would come off during the cleaning process. To work, he believes tags would need to be embedded in the instrument by the manufacturer.
Another potential application is to use passive RFID sample collection, which is currently cataloged with barcodes and manually. In addition, the hospital is working on a project (with Capsule Tech Inc., Andover, Mass.) to develop an RFID-based bedside platform for patient-specific patient identification and association.
“We are aggressively looking at new and evolving technologies; we are much more conservative on the deployment,” Frisch says.
PUTTING PATIENTS IN CONTROL
One novel application of RFID has been implemented by the Roy and Patricia Disney Cancer Center, part of the 431-bed Providence Saint Joseph Medical Center in Burbank, Calif. The Disney Center, which opened in April 2010, uses a combination of active and passive RFID technology that allows the patient to control his or her immediate environment.
Explains Ray Lowe, regional director for IS operations for the California region, IS director for Providence Saint Joseph Medical Center, and assistant CIO in the California region, the Disney Center was designed “to allow the patient to be in control of some aspects of their lives. We looked at how to create a very healing and soothing environment that is transparent for the patient,” he says. Patients are able to control the ambient environment of the exam and radiation rooms.
The system combines the use of active and passive RFID technology. According to Lowe, one of the biggest implementation challenges was working out the interoperability between the RFID systems and the various building systems. Ultra high frequency (UHF) readers (supplied by ThingMagic Inc.) are used to relay information from passive RFID tags to centralized applications that retrieve patient information to enhance his or her experience. The information includes the patient's preferences to activate customized hospital rooms settings, such as music, lighting, and temperature, as well as the patient's location data.
Healthcare Informatics 2011 March;28(3):44-47
