What is smaller than a pea, made of unbreakable glass, and contains the power to stop penicillin? It's radio-frequency identification (RFID) in a chip, and this one in particular is embedded in the shoulder of emergency physician John Halamka, MD.
Dr. Halamka, the chief information officer at Harvard Medical School, considers himself a pretty good test case for the technology. His tiny implant has the ability to protect him from a life-threatening event: It warns of his penicillin allergy. The little disk allows his entire medical record, to be instantly accessible in his emergency department.
It isn't just peace of mind that motivates Dr. Halamka, but the quest to help illustrate the potential of RFID, which can help trace the spread of disease, keep intricate track of inventory, make patient histories more widely and immediately available while safeguarding privacy, and assist in monitoring patients who are cognitively impaired or otherwise unable to communicate their health status effectively.
It causes no discomfort, he insisted, nor does it pose any danger. It is mostly ceramic with a thin glass layer, so thin, in fact, that it's shatterproof.
But it does have one as-yet unavoidable side effect. It sets off exit alarms in stores that track merchandise using the technology. And, unlike those airline passengers who have to pass repeatedly through a metal-detection portal, shedding keys and jewelry to rid themselves of the trigger, Dr. Halamka is stuck with his, and subcutaneously so.
Explanations to security guards have included lengthy explanations of the implant, and usually, it's been necessary to show his medical license, he said. Even so, such encounters are often followed by comments such as, “OK, so when were you abducted by aliens?” or, more frequently, comparisons with a celluloid cyborg who is part human, part machine.
Health Care Experimentation
Aside from the doorways of stores, RFID is enjoying wide use, and it has been the subject of intense experimentation in health care. At Dr. Halamka's institution, for example, babies in the neonatal intensive care unit wear bracelets bearing the technology, as do other patients, medical personnel, and medicines. In this way, a nurse administering a medication can scan the medicine and the patient, and there will be a record of who gave it, the time of day, what it was, and who received it. As a result, RFID has the capacity to prevent medical errors and to pinpoint how they occurred when they happen, he said.
With such evidently beneficial properties, RFID may sound like a technology that warrants universal support, but it has been anything but that. In fact, it has sparked considerable protest. “It raises an emotional issue for some,” Dr. Halamka observed.
He has been accused of becoming part of a program with dire ramifications by people who have read about his unique participation in the use of RFID and don't like the idea. E-mails have included everything from assertions that he is part of an Orwellian Big Brother movement to the concern that he is fulfilling a biblical prophecy in which bearing numbers is a sign of doom.
Five years ago, inspired by interest in the technology, Mark Roberti founded a publication about it, the journal RFID. RFID “is catching on across many industries,” affirmed Mr. Roberti, a former managing editor of Information Week.
In health care settings, the technology helps meet logistical challenges not entirely solved by bar codes: Pain-relieving drugs can be added and subtracted from the cache of medications without the need for handheld label scanning; gurneys can be detected in those obscure nooks and crannies where they are sometimes stashed.
“You can locate them in real time by looking on a web browser,” Mr. Roberti said. He noted, however, “You don't need to implant anybody to get the benefits.”
A flurry of recent publications seems to lend support for a new, hyperconnected age in which data collection is not only more comprehensive, but a matter of considerable importance to insurers and even patients themselves in determining where to put their consumer dollars. “Corporate purchasers of health care benefits are beginning to demand the use of information technology in health care for purposes of improving quality,” wrote Thomas R. Prince, PhD, CPA, in a review on information technology in the Journal of Ambulatory Care Management. According to Dr. Prince, a professor of health industry management at the Kellogg School of Management at Northwestern University in Evanston, IL, the “level of investment in information technology is directly related to net income for hospitals.” (J Ambul Care Manage 2002;2522.)
The California Healthcare Foundation, a philanthropic organization based in Oakland whose mission is finding ways to improve health care delivery and financing, concluded in 2003 that widespread adoption of information technology could “dramatically improve the processes and outcomes of care.”
Other investigators have indicated a more corporate model is essential for the survival of health care facilities in the near future. A recent publication that looked at how board configurations may affect hospital financial health, for example, found evidence in support of those that more closely mimic corporate boards. (J Health Soc Behav 2006;47:291.) And the advantages of RFID, according to Mr. Roberti, extend beyond improving the way medicine is tallied or easing the quest for lost equipment. RFID has the ability to prevent mistakes.
RFID on an accident victim, for instance, could be used to create a medical record that follows the patient from the trauma scene to the emergency department, so that a drug given during field treatment would not be duplicated once the patient was transported to the hospital. Not everyone sees the beauty in such an arrangement, however.
One of those urging caution is Jim Harper, an attorney and the director of information policy studies at the Cato Institute as well as a member of the Department of Homeland Security's Data Privacy and Integrity Advisory Committee. The use of RFID on equipment, supplies, and medication in emergency departments “makes sense,” Mr. Harper agreed. In fact, the technology is proving to be an effective way to log and follow inventory. And placing tags on wristbands can be a highly efficient way to identify and monitor patients, particularly tiny ones like those in Dr. Halamka's NICU, he added. But those bracelets are shed on discharge.
When RFID ventures beyond the hospital, it raises privacy concerns, said Mr. Harper, the author of the book, Identity Crisis: How Identification Is Overused and Misunderstood, which was published by the Cato Institute last year. (The Cato Institute conducts research and provides expertise on issues involving civil liberty.)
“What is good for products is not good for people,” Mr. Harper said. Systems that use RFID, so far anyway, generally have to rely on the personal touch to distinguish a human being from a bed pan. In a hospital setting, that generally doesn't pose a problem, but wearing or bearing RFID might prove alarming — literally — in other places, as Dr. Halamka learned.
Moreover, using RFID as a way of linking people to their electronic medical records, which would encourage them to have such an identifier with them at all times, is getting the “technology cart before the efficiency horse,” he said, stressing that a bar code is capable of doing that, minus the possible privacy breaches that can occur with RFID. RFID tags used for health care often are indistinguishable, technologically speaking, from those utilized by commercial businesses, he said.
Tracking a patient on a gurney is one thing; following ordinary citizens around in their daily lives is another. “It's an easy dividing line,” he said, noting that when a West Coast elementary school proposed issuing tags with RFID to students so that their whereabouts would be known almost any time, it was the parents who nixed the plan. “This is very threatening to privacy,” he said.
Dr. Halamka acknowledged there may be complications until the technology is refined. One possible worry, at least in terms of the technology's current use, is the potential for “spoofing,” in which RFID tags can be copied or exchanged, possibly allowing for the kind of identity theft seen in illegal credit card use, he said.
The way the technology generally works now is to detect the presence of a chip, but encoding or encrypting capabilities are being enhanced, and they will allow systems to distinguish between a product tag and a personal one, Dr. Halamka stressed.
One objection has nothing to do with privacy concerns, but harks back to the origin of RFID, which, depending on the history source, links its inaugural uses either to government spyware or corporate profit. Mr. Roberti said RFID originally was used to track cattle and to follow trucks carrying nuclear material.
“For 20 years, it was a niche technology used to track re-usable assents, works in progress, and other things in rare cases where bar codes didn't work for one reason or another,” he said. “In the late 1990s, MIT set up the Auto ID Center to research the use of RFID,” he added, explaining what he believes to be the actual birth of the technology.
After evolving, that initial technology gave rise to systems that eventually hit the market, offering “longer read range and potentially lower cost, which was what was needed for using RFID in the supply chain,” he said. RFID's advantages over bar coding include the fact that it is automatic, that it can be read at a distance, and that you usually don't need a line of sight.
Most RFID — at least most short-range, high-frequency transponders — now can be carried in a tag no bigger than a grain of sand, so the technology could be stored in a keychain or a piece of jewelry, Mr. Roberti said.
Medical facilities are climbing aboard the RFID bandwagon. One of the first to jump into RFID was Washington Hospital Center, where active RFID tracks personnel and equipment throughout the facility in a pilot program that uses “ultra-wideband RFID,” which was developed and then declassified by the military. This technology reduces the antenna “chirp” of an active system so dramatically that it is believed to be completely unobtrusive, posing no risk of interfering with other medical technology, said Craig Feied, MD, a professor of emergency medicine at Georgetown University.
Dr. Feied was at the forefront of the use, development, and modification of the system at the flagship hospital of Medstar Health, Washington Hospital Center. There, the value of RFID was demonstrated not only in the expanded capacity for keeping a close watch on inventory, but as a tie-in to data collection that allows for quick and careful review of flow and movement throughout the hospital. The tracking is so sensitive that the actual position of a patient on a gurney, whether supine or sitting, can be detected as the body moves, he said.
This offers tremendous potential for disease control. If infection spreads, it can be traced to the original point of contact, and it pinpoints the subsequent places and people who may have been exposed to the infective agent. Similarly, the route of a contaminant, such as a pesticide, may be traced the same way. This provides a faster, more accurate way to follow the possible trail of contact, he said.
One of the most frequently used applications expedites the hunt for staff. In the ED, for example, an overhead screen reveals all the rooms and occupants, including nurses and physicians, at any given moment. “The average amount of time it usually takes to find someone (without RFID) is three minutes,” observed Dr. Feied. With RFID, in contrast, it takes a few seconds.
The RFID data, from the temperature of rooms to the movement of IV poles, is collected and stored in a system developed independently by a team at the facility and dubbed Azyxxi, which continually records and updates information. With Azyxxi (rhymes with Trixie) providing instant access to information, patient throughput was dramatically increased at the ED, Dr. Feied said.
Last year, Microsoft acquired Azyxxi, and hired key members of the team that developed it. The purchase, which was covered in news accounts, inspired almost immediate predictions for broad market appeal of the system.
The Washington Business Journal noted that the sale of the system to Microsoft meant “the software giant now plans to put database software on the market for health care providers worldwide.” At about the same time, Information Week weighed in with a look at how this may flame competitive forces, leading to benefits for consumers by “IT-driven cost cuts and care improvements.”
Recently, New York Presbyterian Hospital and Johns Hopkins Medical Center recently announced that they will adopt the Azyxxi system.
How important will RFID be to the future of emergency medicine? At Washington Hospital Center, an entire patient history, including every test result and piece of information recorded about that person, from a list of allergies to an array of x-rays, can be accessed in an eighth of a second. “We think RFID location tracking is an important part of that,” said Dr. Feied, now also a general manager of the Health Solutions Group at Microsoft.