Copyright © 2015
John R. Zaleski, Ph.D., CPHIMS
john@medicinfotech.com
Page 1 of 8
Radiofrequency Identification Utility in Healthcare
The application of barcode and RFID technologies in the areas of medication
administration reporting and safety checking is an expanding and accepted use
of these technologies at the point of care. In particular, validating and
verifying patient, drug, and order identity as part of the “5 Rights”1 for
medication administration checking and infusion pump drug validation via the
use of universal product code (UPC) symbol or radio frequency identification
(RFID) embedded patient bracelets is a key step in nursing workflow within
acute care wards. Verifying patient identity is often accompanied by clinician
requests to orally verify patient identity via independent checks for patient
name, dates of birth, and social security numbers.
In the normal flow of clinical operations, identity bracelets are attached during
the in-patient registration process and are typically not removed except by the
patient post-discharge. These bracelets provide the linkage that ensures both
patient safety and identity throughout the hospital stay, oftentimes identifying
not only patient identity but also warning of potential patient allergies,
disease, or syndromes that of which knowledge is essential for proper care.
Examples of typical barcode and RFID readers that are used at the point of care
are shown in Figure 1.
1
(1) Right Patient; (2) Right Route; (3) Right Dose; (4) Right Time; (5) Right
Medication
Copyright © 2015
John R. Zaleski, Ph.D., CPHIMS
john@medicinfotech.com
Page 2 of 8
Figure 1: Typical RFID (left) and barcode readers (photo by author)
While both barcode and RFID have their advantages, the benefits RFID
technologies have over standard barcode include (1) no need line-of-sight
access between the barcode reader and patient bracelet or drug UPC code;
and, (2) no concern over smudging the ink on the bracelet—specifically, the
UPC symbol—which could make tags unreadable. In a clinical setting, inability
to read or process a tag to verify patient identity can impede care.2
Both RFID and barcodes can reduce errors that can occur at the bedside. Yet,
verification of patient identity is only one aspect or use of these technologies
that can improve overall workflow and patient care. Positive patient
identification (PPI) is a necessary adjunct to collecting patient vitals
observations and measurement data. Ensuring that these data are posted to
electronic medical records (EMR) is an enormous benefit to standard patient
care, whether in an acute or home health setting. Patient identifiers normally
accompany and are required adjuncts in the information message typically
known as a results transaction that are generated by most monitoring systems.
These systems usually generate data translated into a precise format that
adhere to the Health Level Seven (HL7) standards. As a necessary link in the
2
John R. Zaleski, “Methods and Techniques to Mitigate Data Collection Errors
During Normal Clinical Rounds.”
http://www.medicinfotech.com/2009/10/methods-and-techniques-tomitigate-data-collection-errors-during-normal-clinical-rounds/ Accessed
4/27/2015
Copyright © 2015
John R. Zaleski, Ph.D., CPHIMS
john@medicinfotech.com
Page 3 of 8
process, patient identification establishes the means by which raw patient data
collected from bedside monitors, infusion pumps and mechanical ventilators
are associated with any particular patient, thereby enabling their flow into the
electronic medical records (EMRs). This linkage or association between the
patient and the data is no small task. To ensure that results and observations
are posted correctly to the patient record, it is necessary to go a step farther
and provide a mechanism to link, or associate, patient identity directly with
the findings collected on the patient. The results-identity linkage can be
created via the information extracted through barcode or RFID, supplied by
reading the bedside patient identity bracelet. The identity read from the
bracelet can then mapped to the patient vitals data. These data can then be
transmitted using one of a number of communication mechanisms (the
aforementioned HL7 being one) to the existing clinical information system,
departmental information system, or EMR.
One workflow for demonstrating this scenario would involve scanning the
patient bracelet at the bedside and then, prior to communicating to the EMR,
tagging the observation data would associate it with the patient prior to
transmission. This approach both reduces the likelihood of incorrectly
identifying the patient with data and improves compliance with data
collection, a necessary adjunct to increase the homogeneity of information
available on the patient, improve the completeness of the clinical record, and
provide the capability for a complete trending of patient data—providing the
overall capability for better patient care management.
Bedside devices for the measurement of vitals data are readily available. Data
can be retrieved from electronic medical devices and collected either
automatically using a synchronous approach or asynchronously as desired.
Figure 2 shows a simplified workflow diagramming this process.
Figure 2: Simplified patient identification and bedside data collection
scenario flow diagram.
The acute care scenarios of collecting data within the healthcare environment
are, perhaps, an obvious use for patient identifying technologies such as
barcode and RFID. However, perhaps an even more apt use would be in the
general management of the elderly patient both within the home and in
Copyright © 2015
John R. Zaleski, Ph.D., CPHIMS
john@medicinfotech.com
Page 4 of 8
assisted living and acute nursing facilities. Estimates by the U.S. Census Bureau
expect the population of Americans aged 65 and older to increase by more than
a factor of two between 2010 and 20503. In my experience, the use of RFID or
Barcode are normally considered in the location and tracking of elderly
patients either in the home or in these facilities. This is becoming even more of
a challenge, especially as the “baby-boom” generation approaches retirement
age. As a fellow baby-boomer, I appreciate this even more. However, with age
comes a proclivity for onset of chronic illnesses. Stroke, chronic obstructive
pulmonary disorder (COPD), congestive heart failure (CHF), diabetes and insulin
management, dementia and macular degeneration are all ailments that tend
towards those of advanced age. Furthermore, the management of these
illnesses in the home will not only assist patients in ensuring higher quality of
life, but will also reduce costs in care management. Home healthcare and
assisted living facility management of disease are poised for major growth in
the coming years. Figure 3, taken from the National Center for Health
Statistics4, chronicles major sources of death. One can see that hypertension,
nephritic syndrome and accidents are on the rise. However, by far, Alzheimer’s
disease (a form of dementia) is advancing at a rate that outpaces all others in
terms of causes of death over the past 20 years. A key issue and challenge for
those suffering from dementia is loss of knowledge and identity. We hear of
stories of elderly individuals who leave their homes and simply forget or cannot
reconstruct where they live, who they are, or where they belong. This is truly
heartbreaking, but it need not continue or even remain a problem.
Technologies exist that can facilitate identity and location of individuals who
suffer from dementia and other chronic ailments. These technologies can also
provide for peace of mind to family members and other loved ones.
3
Source: Population Division, U.S. Census Bureau, August 14th, 2008; Table 12:
“Projections of the population by Age and Sex for the United States: 2010 to
2050 (NP2008-T12)”
4
National Vital Statistics Reports. U.S. Department of Health and Human
Services. Centers for Disease Control and Prevention: National Center for
Health Statistics. Volume 57, Number 14. April 17, 2009. Page 9.
Copyright © 2015
John R. Zaleski, Ph.D., CPHIMS
john@medicinfotech.com
Page 5 of 8
Figure 3: Sources of death from the National Center for Health Statistics.
Accurate, up-to-date and positively identifiable health information on patients
is clearly essential to proper care management, especially in the homebound
patient. But, as I describe above, location management is also a key enabler. In
several of my Web Log posts5,6 I described the experiences I had with my own
father during the last years of his life. My father suffered from the effects of a
major stroke and macular degeneration, both of which occurred independently
but within the last five years of his life.
As I pointed out in these articles, a serious chronic ailment often experienced
by elderly patients is macular degeneration. In my father’s case, he
experienced the wet (or neovascular) form of macular degeneration.
Neovascular macular degeneration affects about 10% of those patients who
5
John R. Zaleski, “Healthcare Information Technology and The Future of
Medicine.” http://www.medicinfotech.com/2009/09/healthcare-informationtechnology-and-the-future-of-medicine/ (Accessed 4/27/2015).
6
John R. Zaleski, “Why Healthcare Information technology Should Matter to
The Average American.” http://www.medicinfotech.com/2009/09/whyhealthcare-information-technology-should-matter-to-the-average-american/
(Accessed 4/27/2015).
Copyright © 2015
John R. Zaleski, Ph.D., CPHIMS
john@medicinfotech.com
Page 6 of 8
suffer from macular degeneration7,8. Currently no means exists to reverse the
effects of macular degeneration, yet therapies for slowing the progression do
exist.
The effects on my father were significant in that he lost his sight. This was
especially difficult since he spent most of his working life involved in
professions that required his eyes. He was a writer and editor, as well as an
advertising executive, first at his own agency in New York City, and then at J.
Walter Thompson. He wrote for and edited trade magazines, including for the
New York Medical Society, and Ford Truck Times Magazine.
Many of us may have similar stories of loved ones. During the years of care,
which constituted the last 10 years of his life, he spent a great deal of time
being shuttled from physician to physician, from therapy to therapy. At the
time I lived in the Philadelphia suburbs and was the primary source of
transportation for him, first from his home, then from his assisted living
facility. During the latter part of his care he frequently only visited his
specialists for evaluation and to verify whether his condition was worsening. As
a testimonial to the cost and time spent, each of these trips to his specialists
required at least half a day to complete, and most of the time for no other
reason than a 15 minute meeting with a physician in which the query and
answer was literally “how are you feeling,” and “as fine as can be.” These trips
took a great toll on him. His ability to travel was seriously curtailed owing to
other ailments he suffered at the time. I did my best to improve the comfort of
the ride, but each one required him to sit still longer than comfortable for him,
and took a great deal out of him.
While we cheerfully made each visit, it occurred to me early on that these
visits could have been facilitated if they were augmented by home monitoring
and evaluation. Home monitoring facilitated by positive patient identification
would have enabled his specialists to communicate with him directly for those
visits not requiring a direct examination, particularly if these were visits to
simply assess progress with therapy. A measure of assurance gained from this
identification strategy would have been the guarantee of identity, ensuring
that the correct information was indeed associated with the right patient, and
7
“Macular Degeneration,”
http://www.stlukeseye.com/Conditions/MacularDegeneration.asp. St Lukes
Eye (Accessed February 4th, 2010)
8
“The Eye Digest.”
http://www.agingeye.net/maculardegen/maculardegeninformation.php.
(Accessed February 16th, 2010)
Copyright © 2015
John R. Zaleski, Ph.D., CPHIMS
john@medicinfotech.com
Page 7 of 8
to assess his general well-being. The use of barcode or RFID technology could
have been quite useful in terms of verifying remote identity and associating
him with his record.
Of course, privacy considerations must be balanced against information flow
and access: where there is a barcode or RFID bracelet there is a patient. Where
there is a patient, there is an identity, a location, and other information that
must be maintained privately from both a clinical perspective as well as
ensuring that no individuals with less than honorable intentions gain access to
said identifying information. Ann Cavoukian, the Information and Privacy
Commissioner of Ontario9, had pointed out:
“If the RFID-tagged item travels with the individual, then
extensive tracking and monitoring of the item is tantamount to
tracking and surveillance of that individual.”
Yet, a balance can be struck. Virtual visits aided with barcode or RFID
technology could also be helpful in establishing location within the residence.
Again, care must be taken so as not to impinge on the privacy of the patient.
Individuals who live alone or are at risk of falls or suffer from chronic ailments
could benefit from some form of oversight, and home health and monitoring
agencies today provide this capability, all within the control of the patient.
The key to ensuring privacy is to (1) guarantee the patient or their legal
guardian is in complete charge of the disclosure of their information only to
those they so designate; and, (2) guarantee that no possibility of undesired
disclosure can occur.
Early on in my father’s illness he lived in New York while I lived in
Pennsylvania. It was quite difficult maintaining or assessing his condition over
the phone. Eventually I brought him down to live closer to me in the
Philadelphia area. Had affordable remote monitoring access been available via,
say, remote tele-monitoring and location management, it would have afforded
me much peace of mind. Perhaps the balance to be struck is to enable
adequate oversight and “surveillance” by the family members, subject to the
patient’s consent. An example use case would be, for instance, virtual office
visits in which information could be securely uploaded (e.g.: retinal imagery).
The patient’s home would serve to provide a more relaxed setting in which to
oversee and evaluate the patient by the care provider.
9
Ann Cavoukian, PhD, Information and Privacy Commissioner of Ontario (IPC),
“RFID and Privacy: Guidance for Healthcare Providers.” Page 21.
Copyright © 2015
John R. Zaleski, Ph.D., CPHIMS
john@medicinfotech.com
Page 8 of 8
In terms of lessons learned and recommendations, my experience, both
professional and personal, has led me to the following recommendations:
1) The privacy aspects of patient monitoring combined with positive
patient identification must be taken into account when considering the
use of identifying technology such as barcode or RFID.
2) Unique identifiers that ensure one patient’s bracelet and identifiers are
not associated or mistaken for another patient’s is critical. Therefore,
deciding when to use barcode or RFID, the data architecture and
implementation should be taken on as part of a larger systems
engineering, integration and architecture assessment within the
healthcare enterprise.
3) The type of data to be collected should be identified early on. This
includes institutional identifiers, the type and quantity of data to be
collected, the frequency of collection, and how the data are to be
collected.
4) The types of data to be uniquely identified are key to how information is
also entered into the patient or electronic medical record. If in the
acute care environment, then this is more easily done through a
combination of the existing vitals and other medical devices normally
present at the bedside.
5) If in a home healthcare or assisted living environment, then some of
these unique identifying data may be collected but there may also be far
more textual and notes-type content. These data will need to be
captured and associated with a patient in the care setting. One possible
approach is to provide the patient with a band that can be read
automatically at the time of nursing or clinical assessment. RFID readers
within the home (passive or active) can be quite useful in automatically
identifying where the patient is and ensuring positive identification.
6) Cost is the issue; who pays for the technology is another.
As the technologies behind barcode and RFID develop, it makes sense to begin
considering their use within the workflows of the enterprise healthcare
environment, to include home healthcare, assisted living and nursing care. As
the baby boomers age, the need for these technologies will become more acute
and recognized to support standard clinical practice.