1. AutoID at Hospital
“Information Rich Environment For Hospital”
In K. Mun, Ph.D.
VP, Research & Technology, EG, HCA
Adjunct Associate Professor, Neurological Surgery, UMDNJ
T: 305-582-722, E: ikm1@aol.com
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2. IOM Report in 1999 What does it mean?
To Err is Human: Building A Safer Health System Medication Errors:
One million patients in hospitals daily
770,000 injuries caused by medication errors per year events occurring in a hospital
39%
38%
physician ordering
drug administration
when there is not enough
11% drug dispensing information to identify each item
44,000 – 98,000 preventable deaths per year uniquely.
5% of patients acquire an infection from a hospital
Barcoding “is an effective remedy” for medication errors, “a simple way to How can we create information
ensure that … all of the steps in the dispensing and administration processes are
checked for timeliness and accuracy.” rich local environment to prevent
errors?
March 22, 2007 AutoID at Hospital 2 March 22, 2007 AutoID at Hospital 3
Traditional ID Issue Identification Technology in 1999
Barcode
Linear Barcode
• Well known technology in many industries
• Lower cost, easy to copy / print
• Manual process
• few digits of identification number / characters
2D barcode
• Reasonably known technology
• Expensive reader,
• Store more data than linear barcode
RFID
Passive RFID
• Smartcard in Europe using 13.56 Mhz tag
• High cost, good security, limited range
• Transaction based automation
Active RFID
• Military products using 433Mhz
• Expensive, good security, longer range
• Proactive automation possible
March 22, 2007 AutoID at Hospital 4 March 22, 2007 AutoID at Hospital 5
AutoID Projects Barcode For Healthcare
1983 – The Health Industry Business Communication Council (HIBCC)
Barcode Project 1985 – First published account of medication bar-coding
Low tag cost 1985 – Medication dispensing
• Disposable items 1985 – Hokanson JA, et al, Am J Hosp Pharm
1985 – Nold EG & Williams TC, Am J Hosp Pharm
Manageable for high volume 1987 – Smith JE & Meyer GE, Am J Health Syst Pharm.
Good ROI 1989 – Medication administration
1989 – Barry GA et al, Am J Hosp Pharm
1991 – Lefkowitz S et al, Hosp Pharm
RFID Project 1992 – Abdoo YM, Comput Nurs
High tag cost 1999 – IOM report: discussed barcode to improve patient safety
• Reusable/durable items 1999 – 1.1% of hospitals (60) using barcode
2001 – FDA announces intent to propose a bar code rule
Better for low volume projects
2002 – 1.5% of hospitals (90) using barcode
Uncertain ROI 2004 – JCAHO make a proposal and drops mandate
2005 – 9.4% of hospitals (560) using barcode
March 22, 2007 AutoID at Hospital 6 March 22, 2007 AutoID at Hospital 7
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3. HCA Barcode Point Of Care BPOC Experience by 2005
# sites # doses # users
HCA 171 115,933,163 65,000
Mercy 010 7,359,897 10,698
UPMC 002 2,103,789 01,800
BSA 001 1,692,561 00,757
March 22, 2007 AutoID at Hospital 8 March 22, 2007 AutoID at Hospital 9
Lessons From BPOC RFID Project
Reviewing available technologies starting 2000
• BPOC does reduce medication errors Passive RFID
Active RFID
• Better documentation possible Defined problems to solve in 2002
Asset management for rental / leased items & theft
Process improvement tool
• An important building block of EMR/EHR
Selected active RFID technology in 2003
Automation / Reliability
⇒ Issues noticed Return-on-investment (ROI) based on existing cost figures
Manual processes Selected a vendor out of nine vendors in 2004
Battery life / Size of tag
Operational experience / future applications
Everybody must be engaged
Barcode labels can be duplicated easily Implemented a pilot system in 2005
A 120 bed hospital
Hospital-wide implementation
Work around is possible
March 22, 2007 AutoID at Hospital 10 March 22, 2007 AutoID at Hospital 11
RFID Tags and Readers RFID Tags and Readers
Tag in mold
Tag-it Smart Labels
implantable tag Infusion Pump w. active tag
UHF tag
RFID Patient Wrist Band and Handheld Readers
March 22, 2007 AutoID at Hospital 12 March 22, 2007 AutoID at Hospital 13
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4. Hospital RFID Applications Hospital RFID Applications
• Patient Wristband 1. Asset Management
• Blood Product Management 2. ER, OR, ICU Management
• Cold Chain Management 3. Patient Wristband
• ER, OR, ICU Management 4. Blood Product Management
• Point of Care 5. Point of Care
• Pharmaceutical Pedigree 6. Cold Chain Management
• Combating Counterfeit Drugs 7. Pharmaceutical Pedigree
• Asset Management 8. Combating Counterfeit Drugs
March 22, 2007 AutoID at Hospital 14 March 22, 2007 AutoID at Hospital 15
Asset Management Why Asset Management?
National average utilization of mobile equipment is 45% -
Managing infants Universal Hospital Services
Managing medical device, consumables Hospitals can lose nearly $1 million a year in medical
equipment thefts alone - HCPro Healthcare Marketplace
Theft prevention, location, storage, readiness
Five to fifteen percent of hospital inventory is written off each
Bio-Medical service, repair, PM year since it can no longer be located or more importantly
serviced - Frost & Sullivan
Rental equipment management
“Equipment moving from patient to patient without going
Managing Patients through decontamination in between has become a
significant issue to JCAHO in regard to infection control in
Managing nurses, technologists and physicians hospitals” - JCAHO Sentinel Alert
To build an infrastructure for future patient safety
improvements
March 22, 2007 AutoID at Hospital 16 March 22, 2007 AutoID at Hospital 17
RFID Vendors at 2006 HIMSS Selection Criteria
• AeroScout 1610 • Parco 7229 Existing workflow / definition of problem
• Agility Healthcare 3450 • Patientree 7224
Tag type
• AwarePoint 1714 • Per-Se Technologies 3623
• Communication Specialists 7938 • Precision Dynamics 0142 Tag size
• Cygnus Inc 4452 • Radiense 5700 Battery life
• Ekahau 1504 • RF Ideas 1851
• Sayers Healthcare 7015
Resolution
• Extreme Integration 5204
• General Data Company 5704 • Scuptor Dev Tech 1252 Dependencies: density of tags, network,
• Healthcare Pilot 7838 • Sun Microsystem 3649
Installation
• Indidge System 7200 • USA Mobility 7850
• Infosys technologies 7703 • Visible Assets 7037 User interface
• MediTek Interactive 7926 • GE Healthcare 4509
Project management experiences
• PanGo 4050 • Siemens Healthcare 1237
ROI (Return On Investment)
March 22, 2007 AutoID at Hospital 18 March 22, 2007 AutoID at Hospital 19
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5. Wireless 802.11 Coverage Tag density at Bio-Med
I I I I
I
I
Power
802.11 Network Design 802.11 Network Design
For data For resolution
100 ft diameter 50 ft diameter
30 ft. ~ 40-50 ft. 100+ ft
Range
* Easily more than 100 tagged items could be in a bio-med service room!
* There are several issues to be considered carefully before using wireless 802.11 for asset management.
March 22, 2007 AutoID at Hospital 20 March 22, 2007 AutoID at Hospital 21
Step A
Other Busier Bio-Med Shop
Primary patient
care areas
covered A
Storage
locations
identified
Low resolution,
only
discriminate
between zones
A&B
B
March 22, 2007 AutoID at Hospital 22 March 22, 2007 AutoID at Hospital 23
Step B Step C
Add Add additional
coverage for readers to
exits for theft identify patient
control rooms and
waiting areas
March 22, 2007 AutoID at Hospital 24 March 22, 2007 AutoID at Hospital 25
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6. Step D
Pilot Configuration
Add additional
readers for full
Device management: tracking, service, rental
coverage. 433 Mhz active tag
Smallest tag to maximize number of items to track
Real-time tracking (few times per minute)
Variable resolution: bed, room, department,..
Manage high density of tags in a room
Minimum additional network traffic
Clean installation: invisible readers
Web applications: support PDA, laptop, …
Less than three years for ROI
To develop additional applications
March 22, 2007 AutoID at Hospital 26 March 22, 2007 AutoID at Hospital 27
Current Status Tagged Items
Installation & staff training done
Few hiccups & push backs
Interfaced to bio-medical service database
Interesting information
Some items not moving
Relationship among unexpected items (rental / discharge
Device service record
Designing new workflows to improve operations
To increase ER throughput
Surgical tool tracking in OR
To improve workflow in ICU
New interface to physician PDA
Less than three years for ROI based on hard benefits
March 22, 2007 AutoID at Hospital 28 March 22, 2007 AutoID at Hospital 29
Clinical Touch-screen GUI Engineer’s Handheld GUI
Zoom In Zoom Out
Select group
View Assets by Floor Sliding Zoom Bar
March 22, 2007 AutoID at Hospital 30 March 22, 2007 AutoID at Hospital 31
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7. Infusion Pump Utilization Issues: Database Entries
Common name used by nurses: Arjo Lift
250 Common name used by industry: Lift/Patient
The device name: Patient Lift
200
150
Manufacture Model # Description
Arjo Hospital equipment Inc. KPA0310 Patient Lift
100 Arjo Hospital equipment Inc. KGA0310 Lift
Arjo Hospital equipment Inc. KKA5020 Arjo Lift
50
Arjo Hospital equipment Inc. KGA5020 Lift/Patient
Arjo Hospital equipment Inc. KPA0310 Lift/Patient
0
Arjo Hospital equipment Inc. KPA0310 Patient Lift
6
6
6
6
6
6
6
6
6
00
00
00
00
00
00
00
00
00
/2
/2
/2
5/2
2/2
9/2
3/2
2
2
0/
7/
Arjo Hospital equipment Inc. KPA0310 Patient Lift
4/1
4/8
5/6
4/1
4/2
4/2
5/1
5/2
5/2
Census Pumps on Floors Total Pumps Arjo Hospital equipment Inc. KKA5020 Lift/Patient
Arjo Hospital equipment Inc. KPA0310 Lift/Patient
April1 through May 30, 2006 Arjo Hospital equipment Inc. KGA0310 Arjo Lift
Single and Multi-Channel Infusion Pumps
Excludes rentals
March 22, 2007 AutoID at Hospital 32 March 22, 2007 AutoID at Hospital 33
Addressing DB Issues 2D Barcode for Local DB
How much information do we need? Minimum change in workflow
Information rich local environment is the key in Reasonable cost for infrastructure
reducing most medical errors. Less physics issues
Solution for item level issues
Manually correct errors in DB Data rich local environment
More info available to reduce additional errors
Katrina factor
To prevent recurring errors
Local DB?
March 22, 2007 AutoID at Hospital 34 March 22, 2007 AutoID at Hospital 35
RFID & 2D Barcode 2D Barcode
March 22, 2007 AutoID at Hospital 36 March 22, 2007 AutoID at Hospital 37
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8. Information Content Cost Structure Issues
Cost effective unifying standard leading to EMR Start-up cost
• Staff badges
• Patient wristband / patient identification
Recurring cost
• Non-IV medication
• IV-medication / smart infusion pumps
• Medical device identification Liability cost
• Blood products
Monopoly cost
Documents of interests
• Positive identification for patient medication safety from
Partners Healthcare Systems
• Working documents from ISBT-RFID Task Force.
• Documents for HIBCC standards
March 22, 2007 AutoID at Hospital 38 March 22, 2007 AutoID at Hospital 39
Cost: Monopoly Foot Notes
Patents Minimize monopoly
Start of new idea / business Break financial links / associations
Intellectual property Stop cross subsidies
More rational patent law
Law, rules & regulations
Protecting citizens by government Maximize competition & innovation
Source of liability Remove 800 lbs snakes
Not empowering rats or termites
Standards
Industry / government sponsored guide lines
Helpful for a wider adoption leading to lower cost
March 22, 2007 AutoID at Hospital 40 March 22, 2007 AutoID at Hospital 41
Operational Processes Savings By An Early Adopter
RFID $4,000,000
Location Identification Positioning Asset
Tracking $3,500,000
Security System
$3,000,000
Inventory Management
$2,500,000
Utilization
$2,000,000
Requisition / Distribution
Operational $1,500,000
Rentals
Process $1,000,000
Safety / Risk Management RFID-Enabled
Management $500,000
Device
Transport
Management $0
Equipment Cleaning Application Year 1 Year 2 Year 3 Year 4
(projected)
Regulatory Compliance
Realized Net Savings to Date: Over $1.5 Million
Clinical Engineering Excludes “cost avoidance” and “soft” savings
Financing / Accounting
March 22, 2007 AutoID at Hospital 42 March 22, 2007 AutoID at Hospital 43
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9. Lessons from Active RFID
Active RFID can be cost effective.
Rental equipment management
Inventory control of equipment: lower the asset level
Better management of PM & service issues
Cost / workflow management
Utilization based on proactive data using active RFID
Must be willing to change workflow
Work-In-Progress
Additional developments
ED & patient tracking
Blood products / Biologicals
Global view of hospital operation
How do you manage database?
What do I do with surgical tools?
Backup information?
What happens without connectivity??
• Natural disaster like Katrina, earthquake
• Remote areas
• loss of power
March 22, 2007 AutoID at Hospital 44 March 22, 2007 AutoID at Hospital 45
Room Level For ED Patient Level
March 22, 2007 AutoID at Hospital 46 March 22, 2007 AutoID at Hospital 47
Real-time Patient Location GUI for Upper Management
Home Equipment Manager Surgical Services ED Manager Bed & Room Manager Other Applications
OR Suite Utilization
In Use
Message Prep
Center Scheduled
Cleaning
Inbox (3) Not Sched
Messenger
Infusion Pump Utilization
In Use
Available
Soiled
Out of Service
Online: 21
Patient-Tag Association
March 22, 2007 AutoID at Hospital 48 March 22, 2007 AutoID at Hospital 49
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10. Comments
AutoID (RFID & Barcode) is being applied in more and more
areas to improve patient safety and reduce cost.
New business model for standard has emerged, which may
create a world-wide monopoly outside of any government
control even beyond US FDA
Cost of AutoID is dropping where competitive pressure exists.
(RFID: 12 - 50 cents passive tags, $15 - $200 for active tags)
(barcode: less than 0.2 cent / 0.5 cent for 1D / 2D )
Emergency Department Metrics
AVERAGE INTERVALS FOR TODAY (minutes) Actual Target CURRENT PATIENTS IN WAITINGROOM
Surgical Services Metrics
Active RFID and 2D Barcode without passive RFID may
160
7
6
%
100
90
AVERAGE BLOCK TIME UTILIZATION
40
COMPLETED CASES
Cases/Hr
Cumulative Cases complement each other well enough to create information rich
local environment, which is critically important in improving
140
80 35
120 5 70 30
# of Patients
60 25
100
80
4
3
50
40
30
20
20
15
10
patient care and reduce healthcare cost for hospitals.
60
2 10 5
40 0 0
7 8 9 10 11 12 13 14 15 16 17 18
1 7 8 9 10 11 12 13 14 15 16 17 18
20 Time of Day Time of Day
0 0
Time to Time to Time in Time to Nurse Doctor Time in Total <15 20 25 30 35 40 45 50 55 60 60+
Triage Registration Waiting Exam Response Response ED Time
Minutes Waiting
March 22, 2007 AutoID at Hospital 50 March 22, 2007 AutoID at Hospital 51
Thank You!
In K. Mun, Ph.D.
e: ikm1@aol.com / m: 305-582-7221
March 22, 2007 AutoID at Hospital 52
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