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Building a Smart Hospital using RFID technologies
c GI - Gesellschaft f¨ur Informatik e.V. Abstract: Technologies of identification by radio frequencies (RFID) experience a
fast development and healthcare is predicted to be one of its major growth areas. After
briefly introducing the common terminology of the RFID field and its current stan-
dards, this paper describes how this emerging technology can be used to build a smart
. Indeed, used in combination with mobile devices in eHealth applications,
RFID helps optimizing business processes in healthcare and improve patient safety.
The second part of this article shows how to use an assets tracking application, called the RFIDLocator, to improve the quality of the hospital services. We developedthe RFIDLocator to support the high requirements for scalability and reliability onecan expect for such an application. An overview of its distributed software architectureis given. A short cookbook presents the required steps for its configuration to theconcrete case of the hospital.
Some critical remarks about RFID technology, the important questions it raises and the barriers it has to overcome to be fully integrated in eHealth applications concludethis paper.
KEYWORDS: eHealth, RFID, EPC Network Standards, smart hospital, workflow Introduction
An alarming statistic from an American healthcare organization [Hea] is that an averageof 195’000 people in the USA died in hospitals in each of the years 2000, 2001 and 2002as a result of potentially preventable, in-hospital medical errors [Hos04].
[Lin00] asserts that “the problem is not bad people in health care–it is that good people areworking in bad systems that need to be made safer”.
The goal of this paper is to show how technologies of identification by radio frequency(RFID) can contribute to build a smart hospital by optimizing business processes, reducingerrors and improving patient safety.
This section starts by a short introduction to the RFID technology and define some of its main concepts and standards. Then a rough description of the settings and equipmentneeded to “RFID-enable” an existing hospital is provided.
The second section describes some interesting hospital use cases that could benefit fromRFID. This section further illustrates that there are already many pilot projects successfullytesting this emerging technology.
Section 3 presents the RFIDLocator application and shows how it can be configured to beused in a hospital illustrated by a concrete tracking example use case.
The conclusion summarizes the main achievements of this paper and enumerates someopen problems that still have to be solved before RFID is fully adopted by the healthcarecommunity.
Terminology and Standards
Radio Frequency IDentification (RFID) is a method for remotely storing and retrievingdata using devices called RFID tags or transponders. An RFID tag is a small object, suchas an adhesive sticker, that can be attached to or incorporated into a product. RFID tagsare composed of an antenna connected to an electronic chip. These chips transform the en-ergy of radio-frequency queries from an RFID reader or transceiver to respond by sendingback information they enclose1. Finally, a computer hosting a specific RFID applicationor middleware pilots the reader and processes the data it sends. RFID has great character-istics: 1. it is possible to scan tags in motion; and 2. since radio waves can pass throughmost solid objects, the tags don’t need to be in direct line of sight of the RFID reader.
Having labeled or tagged objects being identifiable in an ubiquitous and flexible manner isalready a good start. Building a network out of these objects, so that with a unique numberone can easily retrieve information about them, would enable much more interesting usecases. In order to make the dream of a seamless global network of physical objects cometrue, an open standard architecture has been defined: the EPC Network (aka “The Internetof Things”).
The Electronic Product Code (EPC) uniquely identifies objects and facilitates trackingthroughout the product’s life cycle. The EPC is the fundamental identifier of assets in theso called EPC Network. It basically contains information about: 1. the manufacturer of thetagged object; 2. the product class or the nature of the tagged object; 3. the actual uniqueitem. EPCs are often represented as Uniform Resource Identifiers (URI) in order to be usedon large networks and to be easily manipulated and exchanged by software applications.
An example of pure entity representation of an EPC is: urn:epc:id:gid:25.1.12.
The Physical Markup Language (PML) defines a standardized generic markup languagefor information interchange modelling and encapsulating the data captured by the RFIDreaders.
The Object Name Service (ONS) provides URLs to authoritative information relevant to 1In fact this is only true for passive tags. There are also active tags, which have batteries and initiate the communication to actively emit radio signals in order to send information to readers.
an object, as for instance the web site of the object’s manufacturer.
Towards Smart Hospital
As mentioned before, we aim to describe how the RFID technology can help in medicalfacilities and hospitals. Thus, this subsection describes an example RFID enhanced hos-pital, a smart hospital. To start with, many assets and actors of the facilities have to be“tagged”: The medical equipment must embed RFID tags. In the best case the tags should be placed into the devices by the manufacturer and should contain a standardizedworld-wide unique identifier.
The doctors, nurses, caregivers and other staff members wear a “smart badge”2 stor- On arrival, each patient receives a wristband with an embedded RFID tag storing a unique identifier, and some information about him (e.g. a digital picture, a uniquepatient code, etc.) All the patients’ medical histories (aka paper medical files) and other important documents are tagged with self-adhesive RFID labels containing a unique number.
The blister packs and other drugs’ packages all contain RFID labels. These transpon- ders should preferably be EPC compliant.
The bags of blood are attached with a self-adhesive RFID label holding a unique identifier, the hospital tracking number and some important information about thecontained type of blood.
Furthermore, RFID readers are placed at strategic places within the hospital: RFID gates are disposed at entrances and exits of the hospital.
Each operating theater contains a least one RFID reader.
RFID sensors are placed in strategic galleries and important offices. In the best case, every office should contain an RFID reader: either placed next to the door or underthe desks.
The staff members (doctors, nurses, caregivers and other employees) each have a handheld (PDA, mobile phone, etc.) equipped with an RFID reader and possiblywith a wireless (e.g. WiFi) connection to the web.
2Another project developed at the DIUF (Department of Informatics, University of Fribourg, Switzerland) explores the possibilities of so called “smart badges” focusing on providing location-contextual services to themembers of an institution (e.g an hospital) or to the visitors of an event. See [AG06] for more information.
Eventually, while not mandatory for most use cases, EPC Network standards should beused as much as possible. This is especially true for the unique identifiers (EPC stan-dard), the readers (Gen2 EPCGlobal standards) as well as for the application queries forauthoritative information (PML and ONS standard).
Use Cases in a Smart Hospital
This section emphasizes how the use of the RFID (and its related standards) can contributeto create the hospital of the future. It offers a “state of the art” of the RFID technologiesenrolled in healthcare applications.
We envision hospitals and medical facilities where using the identification technologiescan improve the patients’ care, optimize the workflows, reduce the operating costs, helpavoiding severe mistakes (such as patients’ misidentification) and reduce costly thefts.
This section demonstrates not only that several researches goes towards this direction butalso that some sophisticated RFID systems are already being successfully tested (or de-ployed) in a number of hospitals.
Patient Identification
Many health professionals are concerned about the growing number of patients who aremisidentified before, during or after medical treatment. Indeed, patient identification errormay lead to improper dosage of medication to patient, as well as having invasive proceduredone. Other related patient identification errors could lead to inaccurate lab work andresults reported for the wrong person, having effects such as misdiagnoses and seriousmedication errors [Sir03].
In order to cut these clinical errors, to improve patient care and security and also to improveadministration and productivity, several RFID-based patient identification and trackingpilot projects have been launched during the last two years. For instance, in New York’sJacobi Medical Center [Wes05], in the Birmingham Heartlands Hospital [Bir05] or in theGerman Saarbr¨ucken Clinic Winterberg [Bes05].
Concretely, as mentioned in Subsection 1.2, all patients admitted to the hospital are givenan RFID-based wristband resembling a watch with a passive RFID chip in it3. This chipstores a unique patient ID number and some relevant medical information such as thepatient’s blood type, in order to speed treatment. To ensure patient privacy and to avoidthat medical records are improperly disclosed, further medical data are not stored on thedevices but are rather stored in a secure database that links the unique patient’s ID with itsdata.
The caregiver uses a handheld computer with an RFID interrogator (an RFID-enabled 3In other projects [Pat05] the computer chips, which are about the size of a grain of rice, are designed to be injected into the fatty tissue of the arm.
PDA) to read the data encoded on the patients ID bracelets. Over a wireless LAN connec-tion, the hospital staff can access the patient’s encrypted confidential medical history aswell as treatment record and can obtain information on which drugs and what dosages thepatients will require.
Patients will also be able to check their own records by scanning their wristbands usinginformation terminals.
Blood Tracking
A recent report [Dzi03] points out that mis-transfusion errors (i.e. blood transfusion ofthe incorrect type or blood given to the wrong patient) are unacceptably frequent andserious. As quoted in [All02], “in the transfusion environment, misidentification is themost prevalent cause of transfusion errors that result in death”.
According to [Sun05], mis-transfusions typically result from an error made during thebedside check just prior to transfusion. Studies have documented [Saz90] that such er-rors are most likely to occur among surgical patients. Currently the bedside check is doneby humans using eye-readable information, and in operating rooms this task is particu-larly difficult. Indeed, blood is often given under circumstances of extreme urgency anddistraction. Patients are unconscious during the transfusion and cannot state their name,and caregivers in the operating rooms may not “know” the patient as well as nurses onnon-surgical floors.
To address the issue of the bedside transfusion check one should take advantage of newtechnology. Two machine-readable technologies are candidates for the automation of thesechecks: bar code technology and RFID. Barcodes are unsuitable for bedside checks be-cause they require line-of-sight so that a handheld laser can read a flat surface with thecode. This constraint represents an important practical obstacle, especially in operatingrooms where the patient is covered with surgical drapes.
RFID technology does not have the practical problems of bar codes, and recently severalhospitals4 have deployed pilot programs using this technology to track bags of blood torecord transfusions and ensure that correct blood is given to each patient.
In our smart hospital as described in [Wes], each bag of blood arriving at the hospitalgets a self-adhesive RFID label. This chip has memory for storing a unique identificationnumber and information on the contained blood type. These numbers are also saved ina secure database containing details about the blood’s origin, its designated purpose and,once dispended, its recipient. When a nurse wants to prepare a blood transfusion, she usesan reader-equipped PDA to read the data encoded on the blood bag’s RFID chip and onthe patient ID bracelet. The data from the patient and the bag must match before the bloodcan be used. With this solution the overall process of managing blood bags is eased andless time-consuming. Moreover the risk of patients receiving the wrong type of blood isminimized.
4Examples are the Saarbr¨ucken Clinic Winterberg in Germany [Bes06] or the Massachusetts General Hospital and its START (Safer Transfusion with Advanced Radiofrequency Technology) project [Dzi].
Smart Operating Theatres
As mentioned in [Hen04], surgical identification can raise significant problems, accordingto recent federal reports. The Joint Commission on Accreditation of Healthcare Organiza-tions (JCAHO) declared that the most commonly reported surgical errors involved surgeryon the wrong body part or site, the wrong patient or the wrong surgical procedure [Sen01].
The Birmingham Heartlands Hospital [Bir05] is currently running a pilot5 of the RFIDtechnology on patient undergoing ear, nose and throat surgery [McC06]. The aim of thesystem is to ensure the correct operations are carried out on the right patients.
In the smart hospital the patients get a RFID-tagged wristband containing relevant infor-mation and a digital picture of them. The photograph allows the clinical team to easilyconfirm they have the right patient, and the electronic record ensures they perform thecorrect procedure. If the wrong patients enter the operating room, the medical staff isautomatically and instantly warned of the mismatch.
Thus radio tagging makes the operating theatre safer and more efficient. Moreover therisk of litigation resulting from surgery mistakes and the costs they generate should besignificantly reduced.
Drug counterfeiting is an increasing problem: 1. counterfeit drugs reduce patient safety,as they can contain dangerous substances; and 2. pharmaceutical companies lose tens ofmillions of euros to the counterfeit drug trade each year.
This problem is being taken seriously and in February 2004 the U.S. Food and Drug Ad-ministration (FDA) published a report [oHFA04] encouraging the use of RFID to combatit and urging the drug industry to adopt the technology. Coinciding with the FDA’s an-nouncement, several major pharmaceutical manufacturers announced pilots to incorporateRFID into packaging of prescription drugs. For example Pfizer, the producer of Viagra6,plans to spend about e 4 million on a project for supplying RFID tags for bottles, casesand pallets.
The goal is to assign a unique number (the Electronic Product Code or EPC) to eachpallet, case and package of drugs and to use this number to record information about alltransactions involving the product. This provides an electronic pedigree through the wholedrug supply chain, from the point of manufacture to the point of dispensing [Rob06].
According to [oHFA04], by December 2007 all manufacturers, all wholesalers, all chaindrug stores, all hospitals, and most small retailers should have acquired and be using RFIDtechnology (i.e. antennas, tag readers, and appropriate information systems). Thus theywill be able to retrieve the product codes and verify their authenticity by checking the 5This project follows a smaller “pre-pilot” of the RFID tracking system that began in November 2004.
6Viagra is one of the major target for counterfeiting. Five millions of counterfeit pills were seized by author- manufacturer’s database via the web.
All these measures should make sure that the drugs patients take are safe and effective.
Tracking Equipment, Patients, Staff and Documents
Amongst all the imaginable use cases, RFID is certainly best suited for tracking applica-tions. The technology enables an automated and fast tracking of assets, animals or people.
Efficient tracking in a hospital offers plenty of interesting perspectives.
First of all, remember that our smart hospital is equipped with RFID readers at strategicplaces: e.g. main doors, entrances of operating theaters, recovery rooms, exits of themedical histories library, important galleries, etc. Together with the fact that all the medicalhistories (and other important documents) are tagged, it enables us to locate them throughthe use of an assets tracking application like the RFIDLocator (see Section 3). This factcan already help reducing the medical files’ losses. It is worth noting that, according toa small survey we conducted (see [Gui05]) such losses are not so infrequent and maysometimes have bad consequences, both in terms of costs and patients safety. Severaldocuments tracking applications have already been successfully deployed. Most of themlead to a positive ROI (Return On Investment) such as saving 2500 man-hours a year forthe district attorney for Marin County (USA) [Swe05].
Furthermore, using an assets tracking application within the infrastructure deployed forour smart hospital gives us the possibility to locate and trace staff members as well aspatients efficiently. This can help improving the workflow of doctors, nurses and othercaregivers [Hen04]. It can also help to locate them in real-time which is especially worthyfor huge buildings such as hospitals.
Additionally, being able to trace all the tagged equipment introduces an efficient and ac-curate inventory system. Again, a number of corporates have already successfully intro-duced RFID systems for real-time inventories. The most often cited positive effects are thereduction of assets loss. As an example Metro Group, the world’s third-largest retailer, re-ported a improvement of about 18% in goods loss thanks to the RFID technology. Besides,tagging and tracking equipments offers many other use cases such as finer maintenancescheduling, usage statistics of equipment, placement optimization and fast localization ofimportant material.
Eventually, RFID tracking also helps avoiding thefts. This latter fact is the subject of thenext subsection.
Avoiding Theft of Medical Equipment
It is well-known that hospitals own a great number of expensive medical equipments.
What is less known about it is that part of this equipment is stolen on a regular basis7.
As an example, according to a survey [Ran06], more than e 155’000 of material werestolen in 2005 in eleven hospitals of the United Kingdom. Another survey completed byHarvard Medical School reported that the Beth Israel Deaconess Medical Center (USA)was loosing about e 333’000 a year because of stolen and misplaced equipment [Sun05].
Yet, these surveys do not take into account the sidecosts of thefts. Firstly, before beingidentified as stolen, a piece of equipment would have been searched for hours by hospi-tal’s employees. Secondly, the missing material has to be re-ordered by some employees,diverting them from patient care or management tasks. Waisted money is not the onlyeffect of these thefts. The stolen equipment is sometimes vital and its lack may have severconsequences. According to [Ran06], these facts lead the U.K.’s National Health Serviceto explore new ways of protecting high value material.
Once again, the Radio Frequency IDentification can help towards the finding of a solutionto this serious problem. Indeed, as RFID tags are embedded into the medical equipment ofour smart hospital, we are able to track and trace it (see Subsection 2.5 for more consid-erations about assets tracking within the smart hospital). This fact already reduces risks ofthe thefts as the hospital’s technical staff is always aware of material’s whereabouts withinthe buildings. Furthermore, as for anti-counterfeiting (see Subsection 2.4), electronic tag-ging has a preventative effect and can help identifying stolen material. Additionally, RFIDgates at the hospital’s exits can help notifying the security services that medical equipmentis taken out of the building. Nevertheless, access control methods (a very common use ofRFID) can also help by introducing identification procedures for accessing the equipmentor running it.
However, it is important to note that similarly to anti-counterfeiting (see Subsection 2.4)the most embedded in the material the tags are, the most efficient the RFID infrastructurewill be at preventing thefts. Indeed, if the tags can be removed easily (and without conse-quences) by the thief the presented methods loose part of their value. As a consequence,the producers of medical equipment should embed the tags at the factory (on demand oras a standard), or the hospital should have the ability to tag its assets with hard-to-removeelectronic identifiers.
Implementing the Tracking
As mentioned in Subsection 2.5, efficient tracking in a hospital offers plenty of interestingperspectives. Thus, this section is a so called “cookbook” intended to give an overviewof the configuration required in order to enable assets and people tracking in an hospitalusing the RFIDLocator.
7Items such as wheel chairs and intravascular pumps often disappear from emergency rooms or intensive care The RFIDLocator is a web-based application we developed at the Software EngineeringGroup of the University of Fribourg (CH) in collaboration with Sun Microsystems. It isan enterprise application allowing the tracking of assets within a predefined area, such asa building. Special care has been given to use the EPC Network Standards introduced inSubsection 1.1). As a result, the RFIDLocator is a scalable and robust distributed applica-tion whose different components8 are depicted on Figure 1.
Figure 1: Components of the RFIDLocator infrastructure Placing the Readers
We start by defining a plan describing the readers’ placement. Indeed, as the RFIDLocatoris able to track and trace an object within a predefined area equipped with RFID readers,one first need to specify and parse a plan of the readers’ placement into the application.
Let us imagine we want to setup the application for an hospital specialized in brain andheart surgery. In order for the application to work efficiently, we should include all theRFID enabled rooms and galleries of the building in the plan. However, for the sake ofsimplicity this cookbook contains the definition of the following places only: An operating theater (for brain surgery) corresponding to the room number: SH_A1_OPERATING_01. Within the RFIDLocator such internal location identi-fiers are called BusinessLocationNumber.
A main gallery at the department for heart surgery corresponding to the number: Next, we place the antennae connected to the two RFID readers in “strategic” places asshown on Table 1.
8The global software architecture is presented in [FGL06] and more details as well as a detailed manual can Antenna’s ID
In the middle of thegallery heading to the This is now translated into a formalism the RFIDLocator understands, namely the Reader’sConfiguration Formalism. This XML formalism defines a syntax and a semantics thatmodels the placement of RFID readers within the environment. An extract of the resultingXML document is shown on Table 29.
Figure 2: XML extract of the Reader’s Configuration Formalism 9A LogicalAntenna can be composed of several PhysicalAntenna to be able to capture the direction Define the Users of the System
Now that the application is aware of the readers’ whereabouts, we can go on with thedefinition of our environment. The step is to define the “objects” to be traced. Theseare called TraceableObjects within the RFIDLocator. A TraceableObject isvirtually “anything” that can be tagged with an RFID transponder, ranging from equipmentor medical histories to patients and employees.
For this cookbook, we “tag” the patient Irene Blue with a wristband containing an EPCcompliant (see Subsection 1.1) unique identifier: urn:epc:id:gid:35.5.18. Thisnumber has to be attached with the BusinessNumber of the patient, i.e. its hospital-wide unique identifier: SH_06_IRENE_BLUE. This matching is achieved using the webfrontend of the RFIDLocator and it creates a new TraceableObject. Additionally, we“tag” the patient Josh Green in the same manner.
It is worth noting at this point that the web interface of the RFIDLocator is decoupled fromthe core of the application. Thus, the RFIDLocator core could be integrated with a legacymedical system, enabling the patients’ registrations and tracking as TraceableObjects(i.e. objects we can locate) directly through the existing system.
Using the Application
As the readers’ configuration has been parsed and EPC identifiers have been bound toBusinessNumbers we are ready to use the application: Let us imagine Josh Green is driven by a nurse to the operating theater for brain surgery.
When entering the smart theater Mr. Green is identified by the EPC number sent to thereader by his RFID wristband. The system of the Smart Theater (see Subsection 2.3)detects a mistake: Mrs. Blue was scheduled for operation, not Mr. Green! Immediately,the nurse notifies the Doctor of the mistake and queries the RFIDLocator, as shown onFigure 3, to find Mrs. Blue. The application informs her that Mrs. Blue was last seen inthe gallery on the way to the operating theater for heart surgery (i.e. on the way to thewrong operating theater). She can now contact the heart surgery department to inform thatthe patients where switched.
This simple example already shows the RFIDLocator can serve for patients tracking andlocating. However, it is not limited to this particular use case. For instance, using theapplication we may as well: 1. Track the medical equipment in order to locate it quickly,to prevent theft or to optimize its usage and maintenance. 2. Trace the medical staff tooptimize their workflows. 3. Track medical histories to be able to locate them as quicklyas possible and optimize their management.
Healthcare is predicted to be one the major growth areas for RFID. A recent analysis[Ser05] reveals that the RFID in healthcare and pharmaceutical applications markets earnedrevenue of e 306 million in 2004 and estimates to reach e 1’916.6 million in 2011.
This paper describes some interesting applications with promising perspectives. It alsopresents an open-source application and shows how it could be used to directly implementsome of the use cases.
However, it is worth noting that there are still some open problems to be solved before thehealthcare community fully embraces the RFID technology.
One must be sure that the deployment of radio frequency devices does not interfere withpacemakers, heart monitors or other electrical devices that are common in an hosptial.
Furthermore, the consequences and side-effects of radio waves on the exposed humanshave to be clarified. When talking about pasting radio frequency tags on drug packages,there are concerns that exposure to electromagnetic energy could affect product quality.
Furthermore, any technology implementation in healthcare must deal with privacy and se-curity issues. But RFID presents unique concerns because of the possibility of unintendedwireless transmission of healthcare-related information. Unethical individuals could snoopon people and surreptitiously collect data on them without their approval or even withouttheir knowledge. This could occur even after completion of healthcare services if RFID tags remain active. Hospital staff has to feel comfortable with the fact that they can betracked and located everytime. Maybe some “RFID free zones” should be delimited in or-der to fight the “big brother” effect and to preserve the freedom of individuals. From theseconcerns, it should be clear that challenging cryptographic issues are raised in relationwith wireless transmission and that there is a need for clear laws and recommandationsabout the tracking of goods and people.
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