Real Time Location Systems – To Leverage or Not to Leverage

By Beth Bandi, Vice President of Business Development, EDI, Ltd.

PART 1 - To Leverage or Not to Leverage My 802.11 Network?

I am convinced that if William Shakespeare’s character, Hamlet, were alive today and working as the Director of IT or Facilities in a hospital pondering whether to implement an enterprise-wide Real Time Location System (RTLS), he would pose the following question, "To leverage or not to leverage my 802.11 network? That is the question". Hamlet might even ponder over another question: "Is this the right move for hospitals to have a "one highway fits all" mentality?"

Over the last 5 years, hospitals have “slung arrows of outrageous fortune” when deciding whether to leverage their enormous and costly 802.11 communication infrastructures for RTLS in order to track, manage, and secure mobile equipment, staff, and patients.

In laying the groundwork for successfully designing, planning, implementing, and ultimately launching a well-executed RTLS system, I see three main issues. First, the “Six Critical Success Factors”, which I begin my series of articles with. The second and third issues – coming in subsequent EDItions - are “The Good, the Bad, and the Ugly Truths About Creating a Single Communication Highway” and “Thoughts to Consider in Creating Separate but Integrated Tagging Highways”, respectively. These three main issues are critical to solving healthcare problems such as area and room discrimination, cost containment, patient security issues, bed management, and basic patient flow through the use of RTLS systems.

The Six Critical Success Factors

These are the recommended basic fundamentals or building blocks for facilities to follow when taking that leap onto the “tagging highway”:

1. Enterprise-wide Coverage – Knowing the location, status, and movement of equipment, staff, and patients improves productivity and reduces capital expenditures.

2. Location Accuracy – How close is close? Zonal, room level, sub-room level – all critical factors when determining the type of RTLS system or systems you choose.

3. Installation and Maintenance – Installation considerations are a main factor in both the initial cost and ongoing success of an RTLS program.

4. Interoperability – RTLS programs should be supported by standards-based technology (i.e., open API - Application Programming Interface) in order to provide location and status information to end-users and third party application partners.

5. Financial Risk – Remove the financial barrier by partnering with companies that provide shared risk acquisition models.

6. Use the Keep it Simple Stupid (KISS) Method – To understand the time and money it takes to maintain an RTLS program, look at the low hanging fruit to manage first:

• Critical Assets - IV pumps, Wheel Chairs, Beds, C-Arms, Mobile Computers
• Patient Care Staff Members, Housekeeping and Transport, Maintenance Teams
• Patients in the ED, OR, Med Surge
• Infants and Pediatrics

I truly believe that knowing where something or someone is creates an intersection of knowledge, which if harnessed the correct way, can solve many problems facing healthcare workers today, as well as slow the erosion of the healthcare dollar.

YOUR CHALLENGE:how to bring these Six Critical Success Factors to your RTLS planning committee, if you even have or are planning to form one. All of the six factors are crucial, but my favorite is the 6th factor, the KISS Method. Based on my real world experience, I know what it was like to carry the “bag of dreams” for my products and present them to eager audiences. I admit, in doing so, I confused and overwhelmed my audiences instead of providing them with the tools to maximize their program’s success.

Take a look at the big picture for your RTLS program and envision collectively applying these six principles. In doing so, I predict more lively and beneficial discussions, leading to a more superior strategy and overall program.

Let me end by posing another question, via Hamlet, to help in deciding whether or not to adopt these Six Critical Success Factors:

“To be or not to be: that is the question. Whether ‘tis nobler in the mind to suffer the slings and arrows of outrageous fortune, or to take arms against a sea of troubles and by opposing them . . .”

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PART 2 - “The Good, the Bad, and the Ugly” Truths About Creating a Single Communication Highway

This is the second installment in my series of articles designed to help you lay the groundwork for successfully designing, planning, implementing, and ultimately launching a well-executed Real Time Location System (RTLS). The first article dealt with the “Six Critical Success Factors”. This article addresses “The Good, the Bad, and the Ugly” truths about creating a single communication highway.

I have witnessed firsthand over the last 15+ years the evolution of RTLS single communication highways. This in no way, shape, or form makes me an RTLS expert, but it does give me enough information worth sharing and worth looking at. Where are hospitals getting bogged down today when it comes to choosing RTLS tracking systems? Should they have all tagging solutions on one single highway or multiple highways? What’s hot and what’s not?

To begin with, let’s examine the evolution of RTLS, just so we have a reference point. The first true RTLS active systems in hospitals were infrared-based (line-of-sight, like your remote control) and were integrated with nurse call systems. These systems were designed to assist nurses and/or caregivers with enhancing in-room patient communications through location of staff members, seamless call cancellations, and documentation that patients did indeed receive a higher level of care.

The upside to this system was better visibility of the care team, quicker patient response times, and a way to document in-room patient response and care. The downside was that it was very expensive and costly to maintain, was prone to caregivers being non-compliant about wearing the tag or “big brother,” and had technical issues of not being “seen” with the tag on because the light source was shielded. The result was a system perceived as too costly for tracking nurses only, without the benefit of a fast ROI. Thus, facilities could not justify the rollout of an enterprise system.

The next logical step to increase the odds of a faster ROI was to add more tag types to the infrastructure, such as asset and patient tags. Though welcomed with open arms, there were still severe limitations: the “size” of the tag or form factor; poor battery life (less than 6 months); and server limitations that did not allow coexisting, multiple tag types on the same infrastructure, thereby slowing transaction times to a crawl.

Because of these limitations, the hospital industry was very apprehensive and slow to adopt these systems, greatly hampering the expansion to hospitals’ enterprises. The “Wow Factor” was there, but the cost barriers prohibited rapid adoption. New manufacturers came to the forefront with “new and improved” systems, but limitations persisted and there were no real market leaders.

Again, the hospital market lagged in adopting a single communication highway – why pay money for something that didn’t solve their issues and added nothing to the bottom line!

Circa 2002, wireless pioneer Cisco took the hospital market by storm with the adoption of Wi-Fi. Cisco’s mantra was “One single information highway takes all”. Since then, technology giants, such as Cisco Systems, Nortel, and Meru, have dominated the healthcare space with the notion that “everything that is Wi-Fi-enabled can leverage communications off of an 802.11 a/b/g/n, etc.” Finally, the industry had a “true standard”. Hospitals went from adopting bleeding edge technology to complete standardization and domination of how communications were routed from point to point without building and rebuilding separate and disparate networks.

Think about it - leveraging existing wireless 802.11 networks - WOW! This concept allowed true cost reductions since hospitals no longer had to go through the redundancy of building a separate tagging highway. To the “tagging” world, this was utopia - just add your tag to the network, attach it to equipment, patients, and staff, and off you go. Not so fast though - there was still much to learn and pioneer.

Four main issues surrounding early adopters, with regards to tagging on an 802.11 networks, still remained. First, the bandwidth and its limitations as to how many tags could jump on the network at one time without major latency issues had to be resolved. Imagine - a tag “wakes up” or goes in motion, logs into the network, receives information back from the network, accepts that information, and responds back via the network – all of which takes time. As such, these systems would never be recommended, or acceptable, for use in infant and patient wandering systems, as well as security-focused equipment tracking program. These security-oriented systems are protecting tagged patients and are designed to protect egress areas, such as elevators, stairwell doors, etc. through special tag reader/controllers. Tags that enter these areas must react in real time in order to send information via the tag reader/controllers to maglocks and door contacts in order to lock down the egress point and instantly notify care teams when a breach occurs. Wi-Fi based tagging systems leverage off of existing Access Points (APs) are not technically capable of instantaneous lockdown.

Second, the size and form factor of the 802.11 tags. These tags were close to the size, and weight, of a hockey puck, not to mention their price tag of $120 per tag since they were basically two-way radios.

Third, battery life – tag batteries lasted less than 3 to 30 days. And with bandwidth limitations, as mentioned above, batteries were drained even faster.

Last, but not least, was “room discrimination”. Room level locations were not precisely available using this system. The best granularity with a VOIP grade network was around 8’ to 12’. Since the RFID signal bleeds through structure/density, someone or something could either be on one side of a wall or in a hallway, hampering the ability to provide positive in-room location and affecting workflow, utilization, tracking, and management outcomes.

It’s almost 2011 – what do we have today? To break it down, let’s use an analogy of traveling on the interstate highways. Multiple cars, trucks, semi-tractor trailers, etc. share a system of many highways. Each has their own way of getting from point A to B; no right or wrong highway exists. However, consider the notion that only one option – one highway, one road - exists. Just imagine the congestion and bottlenecks that would ensue!

This is the exact issue hospitals face today when deciding whether to use a single communication highway versus multiple, “best of breed” approaches. IS and Nursing Departments are pushing current R&D initiatives because they are continually requiring more and more leveraging of their existing applications and communication networks. Manufacturers are listening and are constantly evolving and developing new and exciting R&D roadmaps in order to comply with these mandates. RTLS systems are being pushed to be more flexible with greater tag choices, have longer battery life, provide room discrimination versus zonal location requirements, integrate with existing applications, and perhaps leverage off each other’s tagging networks (hybrid networks) in order to ease congestion of using one single communication highway.

That leaves us with one more question and brings us back to the beginning of this article: What is the recommended path for solving the dilemma of whether to use one communication highway or multiple ones? My suggestion, when investigating whether to leverage an existing highway (802.11xx) or bring multiple communication highways (IR/RF, Ultra Sound, Zigbee) into a hospital, is to first address “The Six Critical Success Factors”, which were covered in my first article and are further defined below.

Before taking that leap onto the “tagging highway”, the recommended basic fundamentals or building blocks for facilities to follow are:

1. Enterprise-wide Coverage – Knowing the location, status, and movement of equipment, staff, and patients improves productivity and reduces capital expenditures. You will never achieve goals of workflow and productivity improvement without an enterprise system because hospitals are very complicated and do not function in a linear (manufacturing) capacity. Once you tag someone or something, what do you want to do with the location data?

2. Location Accuracy – How close is close? Zonal, room level, sub-room level – all critical factors when determining the type of RTLS system or systems you choose. Good rules to follow: One, when dealing with patients, the closer the better - room/sub-room level. This is key in high throughput areas such as the ER, OR, ICU, and Med-Surge Departments. Two, when dealing with equipment for tracking and maintenance purposes only, zonal (within 25’) will be sufficient. But, if you want to tie utilization of equipment into the mix, room level will be required.

3. Installation and Maintenance – Installation considerations are a main factor in both the initial cost and ongoing success of an RTLS program. The best and most successful tracking programs are ones that have a dedicated group assigned to the program. These individuals make up different disciplines, such as IS, Bio-Medical, Security, and Nursing.

4. Interoperability – RTLS programs should be supported by standards-based technology (i.e., open API - Application Programming Interface) in order to provide location and status information to end-users and third party application partners. Integrating RTLS systems into existing HIS, ADT, Maintenance, RIS, ERIS, OR, and Bed Management are a current and future trend; however, some RTLS manufacturers have spent time and money creating “best of breed” applications, thereby eliminating the need for some integration. Nevertheless, having open architecture API RTLS systems offer great flexibility and are a must when choosing system partners.

5. Financial Risk – Remove the financial barrier by partnering with companies that provide shared risk acquisition models. Most of the RTLS system manufacturers and integrators offer “trial or pilot programs”, giving hospitals the ability to “kick the tires” of a system without the full financial commitment upfront. It also gives the facility much needed experience and exposure as to how flexible the system is and performs, and whether they like the manufacturer/system integrator who will be installing and maintaining the system for years to come. This is a good way to form a non-threatening relationship that either blooms into a full marriage or parts ways.

6. Use the Keep it Simple Stupid (KISS) Method – To understand the time and money it takes to maintain an RTLS program, look at the low-hanging fruit that must be managed first:

• Critical Assets - IV pumps, Wheel Chairs, Beds, C-Arms, Mobile Computers
• Patient Care Staff Members, Housekeeping and Transport, Maintenance Teams
• Patients in the ED, OR, Med-Surge
• Infants and Pediatrics

These four categories are typical in most RTLS programs and are areas that cause and require the most time, energy, headaches, expense, and liabilities to the bottom line of a hospital.

My challenge to you last time, and now again, is for each facility to create their own “Six Critical Success Factors” study in order to flush out the problems and workflow issues surrounding each category and asset type.

The last 15 years have been very exciting ones for RTLS systems, which are finally being adopted in hospitals as “must haves”. Let’s not forget, though, to give thanks to all of the “bleeding edge” pioneers that have spent unheard of amounts of time and money trying to figure out the best ways to achieve true shop floor management within their facilities. Now is the time to really push the industry to the next level by implementing the right RTLS system(s). Remember, no two highways are the same; but whether it’s one or several, the achieved deliverables and outcomes must be thought through, executed, and administered with confidence.

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PART 3 - Thoughts to Consider in Creating Separate but Integrated Tagging Highways

My first article, “To Leverage or Not to Leverage My 802.11 Network?” laid the necessary groundwork for designing, planning, implementing, and ultimately launching a well-executed Real Time Location System (RTLS). In the second article, “’The Good, the Bad, and the Ugly’ Truths About Creating a Single Communication Highway”, brought some clarity regarding the possibilities that surround implementing multiple tagging highways.

The logical finale for this series would be to consider the possibilities of integrating existing and future RTLS technologies in order to solve the puzzle surrounding the acceptance and adoption of an RTLS system.

As I have referenced several times before in my previous articles, no one manufacturer can adequately, and in good conscience, handle a “one size fits all” approach. There has to be a collaboration or interoperability strategy when choosing an RTLS system based on hardware (Tagging Highway) and software (workflow) applications.

Let’s start with a fresh, updated overview of the current RTLS players. I just came back from the recent HIMSS 2011 National Convention in Orlando, FL, where all the manufacturers were showing their latest, greatest, and futures for the coming 18 months. The top five had great updates and/or upgrades to their platforms and have adequately demonstrated that they can work with most of the software (workflow) applications on the market today. This gives the end-user more options to either integrate with their existing applications and/or explore new application specific solutions offered by the RTLS manufacturer. Basically, the RTLS manufacturers are willing to be more flexible with providing an “open system” versus 5 years ago when they only offered a proprietary one.

As I walked to each of the vendor’s booths below, I had six major points to discuss with each of them. Below is my summarization based on what I spoke with each of them about, regarding their updated features and benefits.

802.11, 433 MHz IR/RF and Zigbee Manufacturers

Number 1: Who had new or updated tag developments to include patient, staff and asset, battery life claims, water proof/resistance, temperature monitoring, and whether tags could be autoclaved?

New/Updates	Versus	Centrak	Ekahau	Aeroscout	Awarepoint
New Tags Patient Staff Asset	Yes, multi-color	No	Yes, patient and staff	No	Yes, early Q3 new line of patient and staff
Frequency	433 MHz	900 MHz	802.11 with IR built in to tag for in room receiver	802.11 with in room ultrasound receiver	Zigbee, 802.15.4
Battery Life	18 months to 2 years	2 to 5 years	4 to 3 years	2 to 3 years	2 to 7 years
Water Proof	Yes – patient	Yes – patient/staff	Yes – patient	No	No
Water Resistant	Yes, all tags	Yes, all tags	Yes, all tags	Yes, all tags	Yes, all tags
Temperature Monitoring	No	Yes	Yes	Yes	Yes
Autoclave	No	No	No	No	Yes

 

Number 2: Who were making strides in room level discrimination – what where the accuracy and granularity guarantees?

New/Updates	Versus	Centrak	Ekahau	Aeroscout	Awarepoint
In-Room	99%	99%	Within 8 to 10 feet w/o IR. Receiver 80% accurate with IR receiver 99%	Within 10 to 15 feet w/o Ultra Sound. Receiver 80% accurate, with Ultra Sound receiver 99%	Early Q3 will guarantee 99%

 

Number 3: Where they adopting of a true open API strategy and who their integration targets are?

New/Updates	Versus	Centrak	Ekahau	Aeroscout	Awarepoint
Open API	Yes	Yes	Yes	Yes	Yes

 

Number 4: Did they solve or are working towards solving scalability obstacles?

New/Updates	Versus	Centrak	Ekahau	Aeroscout	Awarepoint
Scalability Obstacles	Separate hardware infrastructure build out	Separate hardware infrastructure build out	Yes, if adding room level IR receiver	Yes, if adding room level ultrasound receiver	Minimal infrastructure, plug in Zigbee receivers

 

Number 5: What new applications were being developed for bed control, ED, OR workflow management, mobile devices?

New/Updates	Versus	Centrak	Ekahau	Aeroscout	Awarepoint
New/updated applications for bed control, ED, OR workflow management and mobile devices	Yes, and open API to 3rd party applications	Yes, and open API to 3rd party applications	Yes, and open API to 3rd party applications	Yes, and open API to 3rd party applications	Minimal – key driver is open API to 3rd party applications

 

Number 6: Who had hand hygiene solutions?

New/Updates	Versus	Centrak	Ekahau	Aeroscout	Awarepoint
Hand Hygiene	Yes	Yes	Yes	Yes	Yes

 

Number 7: What developments were made towards interoperability with HIS applications or workflow specific applications from 3rd party vendors? 

New/Updates	Versus	Centrak	Ekahau	Aeroscout	Awarepoint
Interoperability	Yes, separate middleware engine	Yes, separate middleware engine	Yes, separate middleware engine	Yes, separate middleware engine	Yes, separate middleware engine

 

I was very excited to see that RTLS manufacturers have finally crossed the proverbial “chasm” and have risen to the top of the hospitals’ capital “must haves”. The large HIS companies all have integrated RTLS systems through their middleware engines or directly through their applications. The key drivers here are open APIs and the interoperability to upcoming EMR, ADT, and HIS applications. RTLS systems are not only asset management systems (which ROI studies have strongly supported), but they now leverage patient and staff efficiencies like never before.

The true benefit of having an enterprise RTLS system is tethering the patient with the clinical staff member and nearest asset to the EMR and ADT systems. This not only allows the clinical staff high-level exposures to potential bottlenecks, but it also gives them the power to make critical decision that drive workflow enhancements - such as turning beds quicker, reducing wait times, reducing surgical case stoppages – all of which equate to increasing revenues.

In closing, I have seen the RTLS industry emerge from an exciting idea through early adoption, and in my opinion, to “ready for prime time” - a journey that has lasted for over 15 years! I truly hope the next 15 years give all of us in the industry fewer gray hairs and allow us to witness firsthand the fruits of our pioneering spirit.

For more information on RTLS, please contact Beth Bandi at EDI, Ltd., bbandi@ediltd.com, 678-213-3542. Or visit our website at www.ediltd.com. 

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