Paaske, S., Bauer, A., Moser, T., & Seckman, C. (Summer, 2017). The Benefits and Barriers to RFID Technology in Healthcare. Online Journal of Nursing Informatics (OJNI), 21(2), Available at http://www.himss.org/ojni
The rising implementation of radio-frequency identification (RFID) technology, specifically in the healthcare sector, demonstrates RFID technology as a favorable asset to healthcare organizations. RFID has the potential to save organizations time and money by providing real time traceability, identification, communication, temperature, and location data for people and resources. The purpose of this paper is to explore the benefits and barriers of implementing RFID technology in the healthcare sector and to provide recommendations to overcome potential barriers. Promising benefits related to the implementation of RFID in healthcare were patient safety, patient and asset tracking, efficiencies in patient care, and provider satisfaction. Common barriers included economic, technical, organizational, privacy, and security challenges. Suggested strategies to overcome these barriers included financial analysis of risk benefits, extensive testing of technology prior to implementation, educating staff on technology pre-implementation, and the acknowledgement of the need for appropriate security measures to ensure patient privacy. Implications for nursing practice included improved patient identification and increased efficiency of care. It was concluded that future research is needed in areas related to cost effectiveness, return on investment, radio frequency interruption due to infrastructure, and security.
Utilization of health information technology (HIT) to improve patient safety and quality of care has become an area of high priority for the U.S. government and healthcare organizations. The Health Information Technology for Clinical Health (HITECH) Act mandates the implementation of new healthcare technologies and promotes the development and use of new HIT to further improve healthcare in the U.S (Health IT Legislation, 2015.) The U.S. Department of Health and Human Services and Food and Drug Administration (2016) strongly recommended and encourages the adoption of HIT and the development of effective real time monitoring systems. Based on the Institute of Medicine (IOM) and National Coalition of Healthcare (NCHC) reports, U.S. healthcare expenditures in 2009 totaled $810 billion and 20-30% of all direct health care outlays were a result of poor quality care, consisting primarily of overuse, under-use, and waste (Yazici, 2014.) These reports indicated that health care costs will increase drastically and researchers have noted that the use of HIT can improve efficiency which may lead to potential savings.
The healthcare sector recognizes the critical goal to adopt and effectively use HIT. With strong institutional powers and policies pushing for the use of these technologies to better support service delivery, radio frequency identification (RFID) technology offers many opportunities for healthcare transformation (Wamba, Anand, and Carter, 2013.) These opportunities and benefits have been recognized in other business sectors and in the pharmaceutical sector where the technology has been adopted to prevent counterfeit pharmaceuticals from entering the marketplace. Wamba et al. (2013) stated that RFID technology offers an improved method for reducing errors in patient care, facilitating tracing and tracking of patients and equipment, promising better management of healthcare assets, and improvement in the process of audits and forecasting capacity.
Radio Frequency Identification (RFID) is a fast developing technology that utilizes radio waves for data collection and transfer (Rosenbaum, 2014). Historically, RFID technology has been used in supply chain management, primarily to track goods in warehouses (Bowen, Wingrave, Klanchar, and Craighead, 2013). RFID has been found to improve cost saving measures and increase efficiency in a range of enterprises (Gulcharan et al, 2013). In recent years, its usage and benefits have been explored in the healthcare sector. RFID has the ability to capture data automatically without human intervention. Compared to barcode scanning, RFID does not require line-of-sight for readers to capture information from tags. A RFID system typically consists of a transponder (tag), a transponder reader, and a database software application (Rosenbaum, 2014). Transponders can be active or passive. An active transponder has its own energy source, while a passive transponder uses the transponder reader as its energy source (Perez et al., 2012). The transponder reader uses radiofrequency signals to obtain data from the tag, including the identification values, information encrypted in the tag, and its location (Alqarni, Alabdulhafith, and Sampalli, 2014). Data collected from the transponder reader is then sent through a local area network (LAN) to a database installed on a server. Users can then retrieve the data using an application installed on the server (Togt, Bakker, and Jaspers, 2011).
While RFID has been implemented in various industries, including healthcare, limited adoption and use of RFID remains a challenge (Chong, Liu, Luo, and Boon, 2015). Despite its potential to help healthcare providers improve efficiency and patient safety, there are several setbacks to its adoption (Gulcharan et al., 2013). The aim of this literature review is to explore the benefits and barriers of implementing RFID technology in the healthcare sector and to provide recommendations to overcome potential barriers.
CINAHL and PubMed databases were used to conduct a comprehensive review of the literature to explore the benefits and barriers of implementing a RFID patient tracking system. The following search qualifiers were used: “radio frequency”, “patient identification”, “tracking”, “patient outcomes”, “benefits”, and “barriers”. Search limiters included electronic full text, peer reviewed, and 2009-2016 and publications printed in English language. This search originally returned 108 articles, after filtering out irrelevant and duplicate articles, 81 articles were omitted. This search criterion produced 27 usable articles. The studies reviewed in this paper included descriptive and experimental designs, as well as literature reviews.
The use of RFID offers many benefits to the healthcare industry related to patient safety, tracking, efficiencies in patient care, and provider satisfaction. Research shows that RFID can help to improve patient safety. RFID tags provide the ability to reduce misidentification issues in healthcare (Alqarni et al., 2014). Ohashi, Ota, Ohno-Machado, and Tanaka (2010) conducted a study using RFID technology to authenticate patients and medical staff during interventions such as medication administration and blood sampling. The study evaluated whether or not the RFID technology identification and confirmation methods were efficient and effective in the prevention of medical errors. The results of this study showed that the system correctly identified medical staff, patient ID, and medication and blood sampling data in real time. Ohashi et al. (2010) examined 27 workflow patterns for each of the three clinical interventions (administering IV medication, injection, and sampling blood) that were tested that provided 81 clinical scenarios. The study found that the point of care system using RFID technology was effective at recognizing individuals and medications. No critical errors occurred during the trial. With the implementation of RFID technology in the operating room, Ku, Wang, Su, Liu, and Hwang (2011) found an increase in patient identification verification from 75% pre-implementation, to 100% post-implementation. Physician time-out completion rates improved from 43% to 70%. Instrument loss decreased from 0.146% to 0.089%.
Accurate patient tracking using RFID technology can improve patient safety in many instances. Okoniewska et al. (2012) found that RFID technology used for threshold monitoring was effective in monitoring patients and equipment. Threshold monitors placed in 20 locations were found to have a 100% accuracy rate when detecting an event with an immediate notification on the application. It was acknowledged that this technology could have utility when tracking wandering patients with elopement risk, particularly with patients who suffer from Alzheimer’s and dementia. In the realm of newborn monitoring, RFID is being utilized to aide in the matching of newborns to their mothers and abduction prevention purposes. One RFID system utilized in a North Carolina hospital was effectively able to notify staff of an infant abduction, allowing immediate intervention and recovery of the newborn (Wyld, 2009).
RFID technology has the ability to improve hand hygiene tracking practices and compliance, potentially preventing hospital-acquired infections. Direct observation is an unrealistic practice for continuous monitoring of hand hygiene compliance. Often the staff knows that an observer is present and recording and therefore results are skewed. Other times the observer may not be within a direct line of sight to observe complete compliance. Real-time continuous automatic hand hygiene recorders give healthcare organizations the ability to record compliance that is lacking with a direct observer. Boudjema, Dufour, Aladro, Dequerres, and Brouqui (2013) examined the accuracy of a RFID device in the tracking of hand hygiene practices. The study used RFID technology to detect hand hygiene events along the healthcare worker’s path during their patient care. The RFID data was then compared to video surveillance to record the accuracy of the RFID. It was found that the system correctly recorded 93.5% of hand hygiene use on a workers path. Filho et al. (2014) found similar results with a 92% accuracy rate of the hand hygiene RFID tracking system.
Ku et al., (2011) identified characteristics of RFID technology that can improve efficiency of care. The article stated that standard barcode readers can only analyze one piece of data at a time, compared to a RFID device. RFID technology consists of a microprocessor that can track a large amount of data wirelessly without ever having to connect to a reader device. This allows for real time tracking of patients, medications, and equipment. RFID sensing chips and active RFID tags send and receive information by wireless radio-frequency messages allowing for automatics information acquisition and automatic sharing.
Coustasse, Meadows, Hall, Hibner, and Deslich, (2015b) stated that RFID can automatically track product receipt/transfer and inventory management. RFID can increase efficiency over standard barcode technology by reading multiple tags at once. Tags are able to store more information per chip than a barcode, and wireless scanners that have the ability to instantly identify and capture data when within scanning range. Saito, Suzuki, Torikai, Hasewaga, and Sakamaki (2013) suggested that RFID technology can ultimately replace many functions performed by barcode scanners if the cost point can be lowered.
Bendavid and Boeck (2011) conducted a study to look at the benefits of RFID technology in healthcare supply chain tracking. It was found that the use of RFID provided rapid, efficient, and accurate tracking of data for healthcare supply chain members, improved data accuracy, and reduced time spent on administrative duties, and inventory related savings. The data reported by the RFID can be programmed to send a variety of specific information such as medication administration, tracking dressing changes, patient checklists, and tracking patient transfers (Ohashi et al., 2010). Coustasse et al., (2015b) identified RFID semi passive tag technology that sends information alerts concerning the environment around the tag, as a valuable tool for blood product and medication storage. The instantaneous data can keep track of perishable products and send alerts when the temperature changes, the expiration date is up and when it is time to discard. RFID tracking data allows for immediate alert notifications and can streamline the process of bed assignment.
RFID can also improve the efficiency in which healthcare providers are able to render care to their patients. The outcomes of the time motion study performed by Ohasi et al. (2010) found that medication administration times were decreased by 61.5% using the RFID medication cart compared to the standard BCMA program. Blood sampling times were reduced by 67% using RFID technology. Ku et al. (2011) found that surgical time delay rates decreased from 4% to 1%, with the average delay time being decreased from 25 to 10 minutes when using their RFID system. Additionally, it was found that the RFID system benefited families in the waiting area, providing real-time information on their family member’s location, improving the efficiency in which families are updated, and improving service quality.
There were many studies that looked at healthcare provider perceptions of RFID technology. Ohashi et al. (2010) inquired about nurse’s opinions of the technology’s accuracy in recognition, operability, user-friendliness of the screen, medical error prevention, workload, privacy, and workflow efficiency. The evaluation found that overall, nurses were satisfied with the RFID technology. Perez et al. (2012) found staff to be highly satisfied with the RFID technology used for patient tracking and medication traceability. In comparison to the previous study, Perez et al. (2012) evaluated not only nurses, but also reviewed the satisfaction of others affected by the technology, including physicians, pharmacists, and IT professionals. Ku et al. (2011) yielded an 80% satisfaction rate for operating room (OR) nurses after the implementation of RFID technology to track patients. Notably, 82.6% of the OR nursing staff felt that the system improved communication between surgical teams and 91.3% agreed that the technology improved patient identification and promoted safety. Administrative functions of the RFID system included the ability to generate quality indicators such as completion of services, OR turnaround time, and surgical cancellations. Administrative staff had an overall satisfaction rate of 95% with the system.
Although RFID technology is very promising for the healthcare industry, there are several risks or barriers that impede the implementation of this technology which include economic, technical, organizational, and legal challenges. Gucharan et. al (2013) noted several setbacks in RFID systems in their ability to obtain efficient and accurate data transfer, restraints in terms of cost, patient safety and privacy concerns, and monitoring and tracking limitations due to human error. Before successful implementation of an RFID technology system can take place, the risks and barriers of the particular organization must be evaluated to ensure the correct and most appropriate selection of technology.
One of the biggest challenges reported regarding RFID technology is the cost of the system and the system’s return on investment (ROI). According to a recent study by Yazici (2014), the cost of an RFID tag can range from four cents per tag to upwards of $50.00 per tag depending on the capabilities. Tags can be reusable or disposable and have associated costs. Reusable tags are higher in price and require a standardized cleaning technique before the tag can safely reenter circulation. The size of most RFID tags are small and light in weight so as not to be cumbersome on equipment or a patient, however it is easy for these tags to then be carried away from the hospital, causing a loss in tag inventory and therefore an unexpected cost for the organization. The RFID tag readers can range from $1,000.00 to $3,000.00 per reader. A fully functioning RFID system requires tags, readers, infrastructure, middleware, printers, and so on, and can cost an organization millions of dollars (Yazici, 2014). It has been estimated that spending on RFID technology in healthcare could surpass two billion dollars in 2018 (Okoniewska et al, 2012).
Technical limitations such as system errors, RFID tag readability, interference with medical equipment, and interoperability with other HIT also impede adoption. Health information technology evolution has presented interoperability challenges for many institutions. RFID hardware and software has not yet been standardized and therefore presents potential for interoperability concerns across providers (Coustasse et. al, 2015b). System errors can occur for a number of reasons. RFID readers can provide false reads caused by interference in the electromagnetic field by other medical equipment, metallic objects, liquid, glass, and moist environments. Read rates and read accuracy is also affected by the previously mentioned objects and environments (Reyes, Li, & Visich, 2012). Loss of accuracy and reporting of the systems take place in situations where tags are lost or damaged therefore making them unreadable. Without properly working equipment, the system cannot function to its full capacity. Work is being done to improve this technology, however where the reader is placed on the equipment or patient being tracked is vital to the transmission of information (Yazici, 2014). This is an example of human error that must be corrected to prevent these technical barriers. In the previously mentioned study conducted by Ohashi et al., (2010), RFID technology was used to authenticate patients and medical staff during interventions such as medication administration and blood sampling. The results of the tests found some technical issues with the RFID technology including wireless network connectivity, lack of staff knowledge of detection areas when administering medications, and the inability of the radio frequency waves to reach some of the tags on the nurses and medication cart due to ceiling height. Okoniewska et al. (2012) evaluated RFID technology to track staff and equipment location in an acute care hospital setting. The asset tracking capability of the system, used to help users find tagged equipment, demonstrated modest accuracy in locating the asset. Commonly, the asset was found in a distant location from where it was depicted in the system. Time studies showed that the system did not accurately report locations and therefore limited utility was identified. Okoniewska et, al. (2012) also identified the need to frequently calibrate the locating system equipment which is difficult when implemented on a large scale due to time and cost.
Healthcare provider perceptions of utility of a system can present barriers for implementation if there is no buy-in or acceptance. Okoniewska et. al, (2012) conducted an evaluation of a commercially available RFID system which was deployed in an acute hospital setting. Staff surveys and interviews were conducted concerning the accuracy and effectiveness of the system. As previously mentioned, the system provided modest accuracy and therefore the staff’s evaluation of the value was mixed. Specifically, nurses were dissatisfied with the accuracy of the technology in locating equipment and patients and its inability to decrease their search time for equipment. Although training on the system was provided as well as a one-week period of familiarization, survey results revealed dissatisfaction with the end user interface (UI) as well. Suggestions for improvement included visual simplification of the system, clarification with icons, keys, and maps, as well as “cheat sheets” on how to use the system.
In addition to organizational acceptance challenges and concerns, privacy and security concerns arise when considering RFID implementation. Yao, Chao-Hsien, and Li (2012) identified concerns for inappropriate collection, intentional misuse, or unauthorized disclosure of healthcare information due to inadvertent transmission or deliberate interception of the tag information. These concerns for privacy and security are raised due to the surveillance potential of the technology and the sensitive information it contains which could be intercepted by unauthorized readers.
While there are barriers associated with the adoption of RFID technology, the data related to existing adoption is promising. To overcome these barriers, the following recommendations and strategies are offered to aid healthcare organizations in the adoption of RFID technology. According to Modrák and Moskvich (2012), the economic impact of RFID implementation must be analyzed to overcome cost concerns related to adoption. Overall cost to implement and maintain RFID technology can deter organizations from using the technology; therefore a thorough cost benefit analysis should be conducted by an organization prior to implementation of RFID. It would also be beneficial for healthcare organizations to assess the success that RFID has already had in the field of supply chain management. According to Kumar, Kadow, and Lamkin (2011), the requirement of RFID adoption by companies like Wal-Mart have increased its recognition as a beneficial technology.
Due to the technical limitations of some RFID technology, testing of the technology prior to widespread implementation in an organization is recommended. Togt, Bakker, and Jaspers (2010) suggest early performance testing in the implementation process can allow for unforeseen technical issues to be addressed prior to full adoption of the technology. This can also allow an organization to recognize unexpected cost or hazardous interference early in the implementation process. Testing RFID on a small scale in a real-life healthcare setting assures an organization that the technology can fulfill its intended purpose. Since RFID technology capabilities vary from product to product, organizations must assess that the desired product is able to meet the anticipated goal of the implementation. Furthermore, it is suggested by Ting et al. (2011) that limitations of RFID technology be addressed during the preparation stage. Acknowledgement of the limitations of the product will avoid over-expectations and define its capabilities to the users.
The perceptions of healthcare providers have been noted as a barrier to implementation. Education on technology prior to implementation is recommended to ensure staff is aware of its value in practice and can utilize the technology as it is intended. In a study assessing the use of RFID technology in asset tracking, Okoniewska et al. (2012) polled nursing staff on their suggestions related to the utility of the system. It was found that a lack of education on the system and how it works was an area in need of improvement. In order for staff to utilize RFID for its intended purpose, proper training must exist. Ku et al. (2011) found that staff concerns related to additional workload required by the system were resolved through persistent communication and computer education and training that was provided prior to implementation. Rosenbaum (2014) suggested that despite the presence of concerns that may limit adoption of RFID, it is imperative that its value be clear. The value of the technology comes from the data captured. Educating healthcare providers on RFID’s ability to increase efficiency in the workplace through the data captured can help to decrease negative perceptions.
In cases where patient data is stored in a RFID device, privacy and security concerns are a common issue. Awareness by an organization of the potential privacy and security risks is imperative prior to adoption. Weighing the benefits and risks to adoption should be considered before investment (Rosenbaum, 2013). Implementation of appropriate security measures to decrease this risk is recommended. Rosenbaum (2013) suggested that ongoing monitoring and assessment of the performance of RFID technology can help to confirm a well-functioning system. Educating staff and patients on the presence of security measures to decrease risk of patient data compromise may aid in the positive perception of privacy and security practices.
Implications for Nursing
The goal of nursing is to be able to promote health and healing by delivering safe patient care. RFID technology has provided positive patient outcomes in clinical practice through a means of safer patient identification. Positive patient identification practices are at the forefront of patient safety initiatives in healthcare. RFID has the potential to offer more sophisticated services for identifying patients than standard barcode technology due to its ability to report up-to-date data in real time (Coustasse et al., 2015b.) The benefits that RFID can provide for future nursing practice not only includes increased patient safety through identification and real time information transfer and alerts, but also include reduction in time spent conducting administrative tasks. Time to locate material and equipment, and even other clinical staff can be greatly reduced (Southard, Chandra, and Kumar, 2012.) This saved time ultimately results in increased time spent with the patient.
Nurses play a significant role in tracking healthcare organizations resources. RFID technology has the ability to store, transfer, and house large amounts of data regarding patients, staff, and equipment. Resources can be better leveraged with RFID implementation. For instance the history of a product or piece of equipment use can be electronically stored and housed in a data warehouse. Data showing the frequency of use, system errors, or other potential problems can be quickly retrieved and isolated much more quickly (Southard et al., 2012.) In addition, big data can be leveraged from the stored information in RFID technology. Information on use of equipment and devices can be analyzed and used for future cost saving purposes. The use of this big data collection can result in more efficient operations, less room for human error, and higher profits for the institution (Bendavid and Boeck, 2011.)
Implications for Future Research
Alqarni et al. (2014) identified areas of concerns related to security and privacy within RFID technology that would benefit from further research. The authentication phase is identified as the phase of RFID technology where the reader interprets the data on the tag. When the tag reader picks up information such as the item tagged, the location of the tag, and the tag number associated with that item, it can leave the system open to attacks. Previous studies have focused on the utilization of authentication protocols to improve privacy and security. Alqarni et al. (2014) presented the practical use of randomized keys and identifiers as a security protocol. Further research would need to be done to verify the usefulness of secret identification and keys.
Bendavid and Boeck, (2011) noted that the cost of healthcare is rapidly escalating and with high value resources in demand it is important to manage supplies. Limiting waste through better inventory tracking may increase accountability and supply efficiency. RFID applications used to manage healthcare supplies may help offset cost due to waste. Further research regarding the cost of implementation and potential savings will help organizations get a better understanding of RFID potential.
Additional research on radio frequency interruption is needed to identify possible technology barriers which can hinder the adoption of RFID (Ting, Kwok, Tsang, & Lee, 2011). RFID adoption requires extensive site evaluation and testing prior to implementation. The potential for radio frequency interruption by current medical equipment can occur and cause disruption to the flow of data information. There are many technical challenges that have been documented including interface and reliability issues based on the environment in which the system is implemented.
Readability of RFID tags is reliant on the location and position of the tag as well as the read distance of the readers. Site evaluation prior to implementation is necessary to analyze Wi-Fi connectivity and potential equipment that may pose as a barrier for signals. Therefore, adoption of RFID technology requires extensive testing of potential radio frequency interruption to current medical equipment. Future research should focus on maximizing RFID transmission within institutional infrastructure (Bowen, Wingrave, Klanchar, & Craighead, 2013).
With the national mandate from the HITECH act to implement new HIT and improve healthcare delivery, RFID technology has proven to be promising to the healthcare industry. Based on the current literature available, common benefits and barriers to RFID adoption were discussed. Benefits included improvements in efficiencies in patient care and patient safety, advancements in patient and asset tracking, and increased provider satisfaction. Barriers included economic, technical, organizational, privacy, and security challenges. Strategies to overcome barriers should focus on extensive financial analysis of risk benefits, thorough testing of technology prior to implementation, education of staff on technology prior to implementation, and acknowledgement of the need for appropriate application of security measures. RFID technology has the ability to improve efficiency and safety of patient care which has positive implications for nursing practice. Further research is needed in RFID security, radio frequency interruptions, and cost effectiveness.
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Dr. Charlotte Seckman, PhD, RN-BC, CNE is an Assistant Professor and Informatics Nurse Specialist at the University of Maryland, School of Nursing. Dr. Seckman has over 27 years of practical informatics experience in government, private and academic settings serving in roles such as project officer, clinical systems manager, consultant and director of education, evaluation and research for clinical informatics. She has published numerous articles on research endeavors related to the electronic health record, usability, personal health records, clinical decision support and technology to support education. Currently, Dr. Seckman teaches and facilitates a variety of informatics courses in the undergraduate, masters and doctoral programs.
Ashleigh Bauer, BSN, RN, CPEN is a Nursing Informatics graduate student at the University of Maryland, School of Nursing. Ms. Bauer completed her undergraduate education at Towson University and has spent the last eight years as a staff nurse at The Johns Hopkins Hospital in the Pediatric Emergency Department. She is a member of the Sigma Theta Tau-Honor Society of Nursing and the Emergency Nurses Association. She holds certifications in Pediatric Emergency Nursing, Advanced Burn Life Support, and Pediatric Advanced Life Support. Ms. Bauer also holds instructor certifications in Emergency Nursing Pediatric Course and Advanced Basic Life Support.
Tonianne Moser, MSN, RN is a Nursing Informatics graduate student at the University of Maryland, School of Nursing. Ms. Moser completed her undergraduate education at York College of Pennsylvania. She is part of the Pi Chapter of Sigma Theta Tau International Honor Society of Nursing. She has worked as a staff nurse at York Hospital on the GI and cardiac floors. She has worked in maternal child health at Mercy Medical Center for the past 9 years, and has also worked at Dr. Bobs Place, hospice for pediatrics. She is Neonatal Resuscitation Program (NRP) and Cardiopulmonary certified and holds NRP instructor certification.
Stephanie Paaske, MSN, RN, CPHON is a Nursing Informatics graduate student at the University of Maryland, School of Nursing. Ms. Paaske completed her undergraduate education for her BSN at Villanova University. She also holds a BS in pre-veterinary medicine and a BS in Agriculture and Natural Resource Education from the University of Delaware. She is a member of the Sigma Theta Tau International Honor Society of Nursing. She holds certifications in Advanced Cardiac Life Support and Pediatric Advanced Life Support. She is a certified Pediatric Oncology and Hemtology Nurse (CPHON) and completed the APHON Pediatric Chemotherapy and Biotherapy Provider Program. She has practiced for 8 years as a clinical nurse in pediatric oncology at Memorial Sloan Kettering, Children’s Hospital of Philadelphia, and Dana Farber Cancer Institute.