Portal de Periódicos da CAPES

Radio Frequency Identification

2006; Lippincott Williams & Wilkins; Volume: 28; Issue: 3 Linguagem: Inglês

10.1097/01.eem.0000292061.54727.06

1552-3624

Anne Scheck,

Radiology practices and education

Location, location, location. That's the precise information that the only Level I trauma unit in Memphis wanted to know about patients in its system. Where were they during the treatment sequence? Just how long did they spend at each step along the way? And where exactly did the minutes add up? To find out, the Elvis Presley Memorial Trauma Unit of Shelby County Regional Medical Center put to use an emerging technology, radio frequency identification (RFID). By wearing an RFID ankle bracelet, the critically injured and the not-so-critically hurt were followed with the kind of unprecedented detail that could pinpoint areas of delay. After racking up quite a few paperless trails, a few surprises surfaced. “It sort of negated what people thought was a hot spot. It showed x-ray gets a bad rap,” said Brian Janz, PhD, the senior investigator of a formal study on RFID usage. (Comm Assoc Inform Sys 2005;15:132.)Figure: Dr. Todd TaylorOver a one-month period, 665 usable patient records were made, and an analysis showed that bottlenecks were not that common. On the other hand, they seemed to occur at sites where wait times traditionally have been difficult to winnow away — diagnostic testing areas such as CT scanning. “This wasn't earth-shattering in terms of a finding,” noted Dr. Janz. But the data did help staff shorten patient processing times. “It was path-breaking,'' he said. When the results of the study were published, there was immediate interest throughout the medical community, interest that stunned Dr. Janz, who found himself fielding inquiries from across the country. During an era in which much of the emphasis has been on developing ways in which the electronic medical record can be made more universally accessible, a less noticeable technologic trek has been taking place as well in patient tracking. And it is no longer limited to the kind of wristband bar coding that once required handheld sensors at every stop. Now, a device that looks a bit like a wristwatch can send out a pulse to indicate the very room where a patient's gurney has been wheeled and how high off the floor the patient is positioned. Identifying Clogs Todd Taylor, MD, an emergency physician who has steeped himself in such technology over the past several years as a software consultant, said the development comes as no surprise. In his work on positioning and automated tracking, or PAAT, he said there is potential for identifying clogs and snags in the system as they occur, and then acting on that information to unsnarl the problem. He noted that three different systems — Summa Health System in Akron, OH; Albert Einstein Medical Center in Philadelphia; and Christiana Care Health System in Wilmington, DE — already are using a similar though not identical PAAT system by utilizing infrared automatic tracking. As Dr. Taylor put it: “Dead-on accurate” tracking data in “real time” is the future of health care. “Hospitals that do not adopt this technology will not be competitive,” he said. A survey of hospitals using the technology published by Hospital and Health Networks indicates he's right. The magazine found that those who are the most wired have a “leg up when it comes to access to capital.” (www.hhnmag.com.)FigureThe survey, done in conjunction with Deloitte Consulting, McKesson HBOC, and the Healthcare Information and Management Systems Society, showed that, among the nearly 1,200 hospitals included, those that were most involved in using the technology had the highest credit ratings.Figure: Dr. James BigelowSuch medical centers are intensely focused on quality of care issues, and more likely to invest relatively heavily in data systems to help meet that goal. “It becomes a self-fulfilling prophecy,” explained Paul Tang, MD, a reviewer for the survey. Striving for excellence goes hand-in-glove with utilizing technologic know-how. Three years ago, as the chairman of the Institute of Medicine's Committee on Data Standards for Patient Safety, Dr. Tang called on the health care industry to implement the kind of computerization that could track and access health care records. Today he is even more emphatic. “This will be the standard of practice” in the next two decades, said Dr. Tang, the vice president and chief medical information officer for the Palo Alto (CA) Medical Foundation. And EDs will need to help lead the charge.Figure: Ms. Rebecca CadyBoosting Quality One system singled out by the survey was Intermountain Health Care, and it won praise from a senior management scientist at the Rand Corporation as well. “Intermountain Health Care uses their IT systems to examine their processes of care and systematically improve them,” observed James Bigelow, PhD, an author of the report, “Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, and Costs.” (Health Affairs 2005;24[5]:1103.) Intermountain in Salt Lake City, for instance, determined that a prescription of exercise, along with medication, improved back pain. “Examining one's work processes and systematically improving them has a name: continuous quality improvement. Japanese automotive manufacturers did it during the 1970s under the name kaizen. And it is what EDs will have to do, it seems to me, if they are to improve patient flows and outcomes,” he said. Rand researchers found that health information technology would significantly slash costs while boosting health care quality, enhance efficiency that could result in savings of $77 billion or more, and make hospitals safer for patients. Two years ago, the American College of Emergency Physicians issued a report stating that future ED technology would mean that patient processing would be conducted simultaneously rather than sequentially, and that patient care, including vital signs, would be obtained instantly and automatically. But the report sounded more speculative than fact-based, comparing the status quo to some seemingly far-off point: “Experts say the changes seen so far will be dwarfed by the revolutionary transformations yet to come.” In the past couple of years, utilization of developing technology has meant new approaches to some pretty old problems, such as the delivery of medication. But high-tech methods don't necessarily mean lower manpower needs. As professional standards for the use of this technology have cropped up, so have the layers of bureaucracy in some places. Now there is suggested bar code information in hospital standards, for example, because even with high-tech solutions and IT experts at the helm, it isn't enough to put in a newer, safer system; it has to be monitored and analyzed for it to work successfully. In Veterans Administration facilities, standing committees are recommended to identify problems in that system, adding another panel of oversight. (Joint Comm J Qual Safe 2004;30[7]:355.) As the Health and Hospital Network's “Most Wired” survey points out, physicians and patients are being asked to get up close and personal with technology that can be difficult to understand. Or, as Dr. Bigelow, said, “People must change the way they do their work, or you won't see any improvement. By itself, IT rarely improves anything. Rather, it enables improvements, makes them possible or easier or cheaper.” Dr. Taylor put it succinctly as well. “It is a tool, not a solution.” Tracking Patients In Memphis, they learned that lesson well — and the hard way, said Pam Castleman, MSN, the director of the trauma center. In Memphis, where bar coding and RFID have long been the brainchild of a famous corporate resident, Federal Express, it was somewhat difficult for health care staff to come to the conclusion that patients could be tracked as easily as packages. “Packages don't get up and walk around and go to the bathroom,” she said, noting that even restroom breaks could put a lag time in the system that had to be explained. And the RFID technology had such a sensitive sensor that even human tissue would interfere with transmission and reception. So the staff soon learned to put it on ankles instead of wrists, people cross their ankles a whole lot less than they do their arms, she observed. Not all patients were thrilled with the technology, noted Dr. Janz. One patient, a Hispanic man, became convinced the device was some kind of label being used to reflect his minority status. He became so distressed about that perception, he forcibly removed it and flung it across the room, rendering the kind of reading that later required a lengthy explanation about outlier data.Figure: Dr. Brian JanzAs for health care staffers, the RFID technology exonerated some and implicated others. Those familiar with the system said it is quite capable of detecting the chatty employee who is spending a lot of time interacting with patients, an act, it could be argued, that might seem a positive attribute under the former health care system. “Well, what we wanted to find out was where our backlog was, and it did a good job of that,” said Ms. Castleman. But do these minute-by-minute examinations invade the privacy of workers? “The question boils down to: What is your expectation of privacy?” said Rebecca F. Cady, RNC, BSN, JD, the editor-in-chief of the journal JONA's Healthcare Law, Ethics and Regulation. “Work habits have nothing to do with privacy issues.” She likened this question to the one that once surrounded the issue of computer monitoring by businesses, noting that employers who peruse e-mail use have been found to be within their rights. “If you are on the clock, that is your employer's business,” Ms. Cady said. However, a whole body of literature has sprung up documenting one of the big barriers to implementation of new technology, and it isn't financial expense. Instead, it is the human cost. “A large number of health information system projects fail,” wrote Jiajie Zhang, PhD, in the Journal of Biomedical Informatics. (2005;38:1 and 2005;38:173.)Figure: Ms. Pam Castleman“Most of these failures are not due to flawed technology, but rather due to the lack of systematic consideration of human and other non-technology issues in the design and implementation processes,” he wrote. Designing and implementing a health information system is not so much an IT project as it is “human-centered computing.” One of the potential problems of putting new systems in an ED is, of course, the attachment to the old way of doing things. Entrenched habits die hard, particularly for employees who have found them workable, practical, and in the vernacular of that time-honored platitude, “not broke,” hence in no need of fixing. In fact, Dr. Janz and his colleagues in their published study on their trauma center's use of RFID found one of the very aspects that might turn the tide on putting in new technology: the so-called in-house champion. These are the enthusiasts who essentially have the personal power to get others on board. “Project champions help keep projects moving through setbacks and learning hurdles,” Dr. Janz and his colleagues noted in their article on the RFID experience in Memphis. Studies on corporate change show that champions can be important to acceptance, said Dr. Bigelow. A second potentially important force for that shift can be the homegrown effect, in which a system is built or modified by the people who are using it. It gets buy-in.