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Auto identification a panacea for patient safety and traceability in healthcare

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  • 1. Auto Identification: A Panacea for Patient safetyand Traceability in HealthcareThis paper was presented at IIHMR National conference on “Healthcarein 2020: Opportunities and challenges before public health, hospitaland pharmaceutical”. Nov 11, 2006. by (Dr. Nitin Verma)Healthcare is an industry in transition and as such is struggling to understandthe effective use of technology in supporting its future state. Patient safetyconcerns, desired improve clinical outcome and regulatory requirements arecreating demand for more traceability in the Healthcare industry than ever before.In July 2004, a shocking report revealed the fact that 195,000 people die in UShospitals due to likely preventable errors. This number is nearly double andalarmingly higher than the IOM (Institute of Medicine) report that claimed thatnearly 98000 people die in US Healthcare institutions due to medicallypreventable errors. Most future improvements in health care may not come frombetter medicine, but from improved systems engineering. Both Bar coding andRFID technologies, neither "new" in the sense of being recent developments, arevying for acceptance in the healthcare arena. Both of these technologies aredelivering traceability and improving the patient safety while actually enhancingefficiency and profitability. They perform the similar function but usingsignificantly different approach.This paper will document the • Various aspects of patient life cycle where Bar coding/ RFID technology are Contributing. • Brief description of various automatic identification system used in Healthcare • RFID Overview
  • 2. Contribution of Auto Identification Technologies inHealthcareBar coding technology has existed and been widely used in many industries sincethe mid- 1970s. Historically, bar coding has been viewed by the healthcareindustry as strictly a logistics tool, meant to organize and automate inventorymanagement. However, recent reports of the high rate of medical error and theever-increasing costs of healthcare delivery have begun to change this perception.Now it seems, the use of bar codes has as much to do with safety and qualityassurance as it does with automation and cost containment. For the ease ofdiscussion this paper will divide the contribution of bar Coding in to Clinical andNon Clinical Applications.Clinical ApplicationsOne of the paramount concerns of a hospitalized patient is to ensure that his five(5) patient’s rights are met and well taken care. With the regulations requiringpharmaceutical companies to incorporate bar coding onto drug labels, the onushas shifted to hospitals to begin investing in the technology infrastructure. It willhelp them to provide the desired patient safety and thus reduced medical errors.The clinical application where bar coding has contributed significantly can bediscussed under the followingMedication Administration VerificationIn a classical scenario, the physician writes a prescription either manually or eRX.These orders are then sent to the pharmacy by 1. Interphase – in case of eRX using the integrated clinical information and the Pharmacy information system. 2. Pneumatic tube and 3. Human careerThe pharmacist then fills the orders and sends them back to the requestinglocation. These orders are then placed either in the automated drug dispensingdevices or in patient bin on the medication cart. Many of the times the nursewould meticulously follow the physician’s order. She will dispense themedication and record it in patient’s medical record. However 20% of the time the 1nurse makes a mistake according to a study conducted by the IOM. Althoughusing different methodologies two studies arrived at the similar figure, attributingthe cost of a single Adverse medical event in a hospitalized patient between 2,3$2013-$2595. In a paperless hospital before dispensing medication, the nursewould first scan her employee ID which has a bar code then enters the passwordfollowed by scanning the patient’s wrist band containing bar code. The nurse
  • 3. then scans the bar coded medication which automatically records the mediationdetails in the patient’s medical record.Blood Transfusion VerificationBlood transfusion errors have long been a source of concern for hospitals andclinics. The blood-handling process at many healthcare facilities contains anumber of manual steps, which can introduce human error. The most commonoccurrence of the error is the incorrect labeling of samples taken either by blood 4specialists or other staff. A study by Sharma et al has shown that nearly 80% ofblood transfusion errors are related to bedside errors or labeling errors, and thatblood bank errors account for approximately 13 % of errors. The primary cause oflabeling errors is either confusion or overwriting of the patient’s hospital IDnumber. Within the blood bank, errors are caused by human factors, cross-checking errors, and mistakes by staff that is performing multiple rolessimultaneously.With the use of bar coding technology, the nurse enters the system by scanninghis or her name badge and entering a secure password. The nurse then scans thepatient’s wristband, and responds to a series of electronically displayed prompts,scans the blood product, the blood product. This verifies the patient’s blood type,the blood unit number, and expiration date. If all prompts are accurately executed,the nurse is directed to start the blood transfusion. On the other hand if any of theprompts are inaccurately executed (e.g., the patient’s wristband identificationnumber does not match the patient identification number on the blood productbag), an alert is generated. Bedside bar coding systems used in transfusion haveresulted in 100 percent accurate patient identification and are recommended byindustry experts.Laboratory specimen identificationBecause the lab investigation guides the physician’s decision and care, they arethe most frequent investigation performed on a hospitalized patient. Collectingblood specimen is akin to the blood transfusion not only in terms of process butalso the kind of errors occurs in both the process are almost similar. The physicianorders a test and the phlebotomist/Nurse verifies the physician’s order, identifiedthe patient, draws the sample and placed in the appropriate container and thenlabels it. Then the specimen is transported to the lab via human career orpneumatic tube. Using Bar Coding through the Specimen Identification systemcan help healthcare institutions not only meeting the regulatory requirementconcerning the patient safety and reducing medical errors but also meeting theirown institution’s regulatory requirement.Before a phlebotomist begins hi sward round for collection of specimen,collection list information which gets transmitted to the Lab Information System(LIS) by the Clinical Information System (CIS) is downloaded to a hand-held barcode reading terminal that stores each patient’s name, hospital number, lab
  • 4. accession number, and test order. While in the patient’s room to make the draw,the phlebotomist scans the patient’s bar-coded ID wristband to verify identity andtest order match. Once back in the lab, the phlebotomist uploads the informationfrom the terminal to the LIS, giving the lab accurate collection data that includespositive patient ID, phlebotomist ID, time of collection, and time of receipt in thelab. This information is finally sent back to the CIS. Errors and processing timeboth are minimized simultaneously and patient safety is enhanced.Respiratory therapy Respiration therapy is again akin to the medication ordering, where physicianwrites a prescription. This prescription goes to the pharmacy either via interphasebetween pharmacy information systems or through the human carrier. Thepharmacist fills the order and sends it back to the requesting location. Theworkflow of a therapist usually includes delivering medications to a number ofpatients in a defined geographical region of the hospital. The patient that areassigned to a therapist may have several medication prescribed. The registeredrespiratory therapist carries these medications with them when they begin theirround. It is not unusual for a therapist to carry 15-20 different medication vials atone time. It is like either inviting a problem or a an accident waiting to happen“though it is preventable”With the use of Bar Coding technology, the flow would be similar to theMedication Administration Verification, where a respiratory therapist first scanshis employee ID bearing a bar code. Then the therapist scans the patient’s wristband. The scanning of patient’s wrist band displays the prescribed medicationorder and the direction for use by the pharmacist. The therapist then confirms thephysician’s orders on his chart with the orders displayed on the Bar Code at Pointof Care (BPOC). Once the medication has been administered to the patient thetherapist confirms the transactions in the BPOC system which goes to variousancillary departments like Billing etc.Dietary ManagementBar coding is playing an important role even in the dietary management. Dietarymanagement system completely automates the three major functions performed inthe Dietary department of the hospital— maintenance of patient records,manipulation of individual patient menus, and management of prescribednourishments/ supplements. A generous amount of statistical information is alsoderived from the data maintained in the System and is made available for clinicaland management useIn a usual process of diet management, the physician’s recommended dietrequests goes to the kitchen either through a human career or an interphasebetween the clinical information system and the Diet management system. Theseorders gets printed, prepared in the hospital kitchen and there verified by the
  • 5. dietician and then delivered to the patients. Considering a scenario of DietaryManagement in Hepatic Encephalopathy, where Protein restriction is part oftreatment with 20 g protein/day and, with clinical recovery, 10 g increments areintroduced every 3-5 days, as tolerated by the patient, to a limit of 0.8-1.0 g/kg 5body weight . This is usually considered sufficient to achieve a positive nitrogenbalance. This practice continues despite evidence showing that patients withstable cirrhosis have a higher protein requirement than normal. Now visualize acase of Acute Hepatic Encephalopathy where increasing protein intake may 6worsen the condition in 35% of patients . Use of branched chain amino acids mayimprove nitrogen balance but without producing any clinical improvement in theencephalopathy. There are several scenarios where a tray can be exchangedbetween two patients of same name, location etc and imagine how disastrous itcan be?With Bar Coding and using a BPOC product, the chances of these kinds of errorscan be reduced significantly. With Bar coded food tray delivery, the attendant firstscan his/her employee ID badge bearing a bar code then enters a unique passwordto enter the diet management system. The attendant scans the patient wrist bandbar code which enables the patient’s diet profile and the bar code from the tray.Successful match prompt pops up when there is a complete match for theattendant, patient and tray’s bar codes.In Vitro FertilizationIn 20023, two proud and relieved parents, Mr. and Mrs. Andrews, saw theirnewborn twins for the first time, conceived after 15 long year and difficult courseof IVF treatment. At last it all seemed worthwhile except the babies were of mixedrace, while both parents were white. It was a shock for them. They wereundergoing IVF Treatment at a very reputed infertility clinic in Chicago. The IVFclinic blundered and used the wrong sperm to fertilize Mrs. As eggs. The childsbiological father was Mr. B, a man the couple had never met and who with hispartner was also trying for a family using IVF.All this happened in spite of “Double Witness” A mechanism where the clinicalEmbryologist is required to ask a colleague to witness and document everyprocedure in which an error can occur. But with more than 25-30- procedureduring each round of IVF make it very labor intensive and still leave the room forhuman error. Similar accidents have happened in the UK, Netherlands and rest ofthe globe.With use of RFID, the procedure can become almost full proof. The sperm andrelated eggs are tagged with RFID a tag ensuring the resulting embryo istransferred to the correct mother. If Clinical embryologist/lab personnel try to usethe wrong samples by bringing sperm and eggs from different couples into the
  • 6. same work area, for example, the system automatically sounds an audio andvisual alarm thus eliminating the human error.Non-Clinical ApplicationsTrackingAny article in hospital setting that can be identified using numeric or alphanumeric codes can be tracked using bar code technology. Bar coding is currentlyused in the tracking of material management, Central Sterile Service Department(CSSD), Medical Record Department (MRD) and clinically in the areas ofPharmacy, Laboratory and Radiology. However the technology is entering in tonew areas everyday to improve patient safety and efficiency.ValidationIs the cognitive process of establishing the truth about anything. In Healthcare it isan effective method of ensuring quality and patient safety. It ensures that aprocess has been completed or can be completed because required supply/drug etcis available in stock. The most important function of validation in hospital is toensure that the patient being treated is in fact the right patient. Similarly themedication being administered or is yet to be administered is the right medicationand that too at the right time in right dose.Inventory ControlHealthcare institutions across the globe are struggling to perform a tediousactivity of Inventory Control. Whether it is surgical, medical or supply for lab,radiology or pharmacy, the inventory is always managed in a combination ofcentralized and decentralized fashion. The consumable inventory is maintained atdecentralized locations in OPD/Wards/Theatres and then at the central location tosupport these decentralized locations. Bar coding and RFID is helping, not only insupervising the utilization structure of a supply and thus lowering the inventorylevel at a decentralized location which has much higher inventory than itsconsumption but also helps in managing these diffused consumable supply.As Hodge explains, "A hospital that has 500 beds might have 95 IV pumps. Thosepumps have to go through preventive maintenance every 6 months. If you askthem where all their IV pumps are, 50% of the time they wont know where 30%of the pumps are. They wont know when the last time they were maintained. Iftheyre not maintained, when they go to use them and the readings are notcorrect, it could potentially hurt a patient." 7
  • 7. Automatic Identification systemsBarcode SystemsThe technology of creating and reading these "zebra stripes" have held their ownagainst other identification systems in past 20 years. The barcode is a binary codecomprising a line and spaces arranged in a parallel configuration. They arearranged according to a predetermined pattern and represent data elements thatrefer to an associated symbol. The sequence, made up of wide and narrow linesand spaces can be interpreted numerically and alphanumerically. It is read byoptical laser scanning, i.e. by the different reflection of a laser beam from theblack bars and white gaps. However, despite being identical in their physicaldesign, there are considerable differences between the code layouts in theapproximately ten different barcode types currently in use:Optical Character RecognitionOptical character recognition, usually abbreviated to OCR, involves computersoftware designed to translate images of typewritten text (usually captured by ascanner) into machine-editable text, or to translate pictures of characters into astandard encoding scheme representing them in ASCII or Unicode. OCR beganas a field in artificial intelligence.Biometric procedureBiometric is defined as the science of counting and (body) measurementprocedure involving living beings. In the context of identification systems,biometry is the general term for all procedures that identify people by comparingunmistakable and individual physical characteristics. Biometric procedures mostcommon in use are voice identification, finger printing and hand printing and lesscommonly retina or iris identification Voice Identification: With rapid advancement in healthcare technology, voice identification in user identification is gaining acceptance. The sophisticated equipment converts the spoken words in to digital signals for evaluation by the identification software. Finger printing procedure (Dactyloscopy): The most mature, most widely accepted and therefore most often used biometric technology is fingerprint recognition. In the healthcare environment fingerprint biometrics is used to protect the security and confidentiality of electronic health information, control and manage physical access rights to authorized rooms etc
  • 8. Smart CardA Smart Card is a credit sized plastic card with a special type of integrated chipembedded in it. The integrated chip holds information in electronic form. Theyare smart because they control who accesses this information and how i.e. readonly, updateMemory cardsIn memory cards the memory component is called EEPROM, which is accessedusing a sequential logic. It can also incorporates the security algorithms i.e.stream ciphering.Microprocessor cardsThey contain a microprocessor which is connected to a segmented memory as thename suggests. They are primarily used in security sensitive applicationRFID OverviewRFID systems are closely related to smart cards, where data is stored on anelectronic data carrying device - the transponder. However unlike the smart cards,the power supply to the data carrying device and the data exchange between thedata carrying device and the reader are achieved using magnetic and electromagnetic fields.What is RFID?RFID (Radio Frequency Identification) is a method of identifying unique itemsusing radio waves. Typical RFID systems are made up of 2 major components:transponder or the tag and the interrogator or the reader. The tags are usuallyapplied to items, often as part of an adhesive bar code label. Tags can also beincluded in more durable enclosures and in ID cards or wrist bands. Theinterrogator or reader can be standalone unit or integrated with a mobile computerfor handheld use.How RFID WorksRFID systems works according to one of two basic procedures: full duple(FDX)/half duplex (HDX) systems and sequential systems (SEQ).In FDX and HDX system the transponder’s response is broadcast when thereader’ RF field is switched on. Because the transponder’s signal to the receiverantenna can be extremely week in comparison with the signals from the readeritself, appropriate transmission policies must be used to differentiate
  • 9. transponder’s signal from that of the reader. In practice the data transfer fromtransponder to reader takes place using load modulation.In contrast, sequential procedure employs a system whereby the fields from thereader is switched off briefly at regular interval. These gaps are recognized by thetransponders and used for sending data from the transponder to the readerVarious features of RFIDFeature AttributeOperation Type FDX SEQData Quantity > 1 bit 1 bit EASProgrammable Yes NoData Carrier’s IC SAWOperatingPrincipleSequence State Machine µPPower Supply Battery PassiveFrequency range LF RF MicrowaveData Transfer, Sub harmonic Back scatter/Load OtherTransponder→ modulationreaderResponse 1/n-fold 1:1 VariousFrequencyOne very important feature of RFID system is the power supply to thetransponder. Passive transponder does not have their own power supply, andtherefore all power required for the operation of a passive transponder must bedrawn from the (electrical/magnetic) field of the reader. In contrast, Activetransponder incorporates a battery which supply all or part of a power the powerfor the operation. Another important characteristic of the RFID systems is theoperating frequency and the resulting range of the system. The differenttransmission frequency is classified in to three basic ranges. Low Frequency(125/134 KHz) – LF: Most commonly used for access control, and asset tracking.High Frequency (13.56 MHz) – HF: Used where medium data rate and readranges are required. Ultra High Frequency (850 MHz to 950 MHz and 2.4 GHzto 2.5 GHz) – UHF: Offers the longest read ranges and high reading speeds.A further subdivision of RFID systems according to range allows to differentiatebetween close coupling (0-1cm), remote coupling (0-1m), and long range (>1m)systems. The different procedure for sending data from transponder back to thereader can be classified in to three (3) groups:
  • 10. 1. the use of reflection or backscatter (the frequency of the reflected wave corresponds with the transmission frequency of the reader → frequency ratio 1:1)2. Load modulation (the reader’s field is influenced by the transponder → frequency ratio 1:1)3. The use of subharmonics (1/n fold) and the generation of harmonic waves (n-fold) in the transponder.
  • 11. 1. Kohn, L.T., Corrigan, J.M., Donaldson, M.S. (Eds.), To Err is Human: Building a Safer Health System. National Academy Press. Washington, DC. 1999.2. Classen DC; Pestotink SL; Evans RS; et al Adverse drug events in hospitalized patients: Excess length of stay, extra cost and attributal mortality. JAMA 1997, 277. 310-306.3. 3. Bates DW; Spell N; Cullen DJ; et al The cost of adverse events in hospitalized patients. JAMA 1997, 277. 307-4. 1R.R. Sharma, S.Kumar, and S.K. Agnihotri. “Sources of Preventable Errors Related to Transfusion.” Vox Sanguinis 2001 81, 37-41.5. Andres T. Hepatic encephalopathy. In: Bircher J, Benhamou P, McIntyre N, Rizzeto M, Rodés J, eds. Oxford textbook of clinical hepatology. 2nd ed. Oxford: Oxford University Press, 1999:765-7836. Riordan SM, Williams R. Treatment of hepatic encephalopathy. N Engl J Med 1997; 337: 473-4797. Automatic Identification, By Judith M. Inglesby, RN MN; Tom Inglesby (http://www.psqh.com/sepoct05/barcodingrfid2.html )