Radio Frequency Identification: Ready for Implementation Decision

John S. Luo, MD

Dr. Luo is assistant clinical professor in the Department of Psychiatry and Biobehavioral Sciences at the University of California in Los Angeles; past president of the American Association for Technology in Psychiatry (AATP) in New York City; and Gores Informatics Advocacy chair at the AATP.

Decreasing medical errors has been a major cornerstone in the drive to improve the quality of healthcare. An Institute of Medicine report ¹ and The Leapfrog Group ² have both identified computer physician order entry as one way to decrease medication errors. However, this process reduces possible errors at the point of order generation and does not necessarily guarantee accuracy and validity at delivery. One of the new technologies to reduce delivery errors in healthcare is radio frequency identification (RFID). It has long been a benefit to the retail industry, from tracking items along the supply chain to protecting inventory in stores. This article will review the technology and discuss its current and potential uses, enabling the reader to decide whether RFID is ready for deployment.

Background

RFID is a mechanism to store and retrieve data using devices called tags or transponders. The RFID tag is a small object usually attached to an object or incorporated into a product. It contains an antenna and a silicon chip to enable them to receive and respond to radio-frequency queries from an RFID transceiver. The three types of tags are passive, semi-passive, and active. A passive tag has no energy source, and only transmits information when activated by the minute electrical current induced in the antenna by the incoming radio frequency scan. The passive tag only transmits limited information such as a number, but stores this information in an electrically erasable programmable read-only memory, a non-volatile storage used in universal serial bus drives. The passive tag has a range of scanning up to several meters. A semi-passive tag is in essence a passive tag with a small battery to eliminate the need to collect energy from the incoming signal, therefore enhancing the transmission signal. Active tags contain a larger battery and transmit the signal longer distances, up to 300 feet. Active tags can also be combined with sensors such as temperature and humidity, and this information can be stored on the chip. The stronger signal range and higher accuracy make active tags more appropriate for more difficult environments such as water and heavy metals.

The advantage of RFID over a bar code system is that direct line of sight is no longer necessary since tags can be read under blankets.³ In addition, RFID can be used on curved and other surfaces compared to bar codes which must be flat. RFID tags are more durable than bar code tags since they do not wear off as quickly. However, RFID costs more per tag, and does not have the stable base of vendors and applications compared to bar code systems.

RFID is used in many commercial settings for a variety of applications. The most common use is theft prevention for small items such as compact disks and DVDs. Wal-Mart has required its vendors to use RFID tags for supply chain management, and in addition many items have sewn-in tags for security purposes. Mobile Oil Company offers its Speedpass system, an RFID tag on a keychain that enables users to quickly pay at the pump and cash register since the transaction is linked to a credit card. They now offer a 5-cent per gallon rebate to entice new users.⁴ Many veterinarians offer RFID tag implants for pets, enabling identification and recovery.⁵ In California and many other states, toll booths offer RFID-based electronic toll lanes for frequent users, bypassing long lines.

Healthcare Uses

RFID technology has tremendous implications for healthcare, with a variety of uses. The Food and Drug Administration has great hopes for RFID to help eliminate counterfeit drugs by providing tracking along the supply chain and establishment of an electronic pedigree.⁶ In addition, the FDA approved use of RFID technology in humans in October 2004 for surgical markers to mark the site of surgery.⁷

In healthcare, patient care assets such as wheelchairs, hospital beds, and infusion pumps are often lost or misplaced. RFID combined with WiFi technology as offered by AeroScout provides a mechanism to keep track of these assets and increase their utilization.⁸ In addition to durable-good tracking, patients and staff can be tracked as well in the hospital setting.⁹ Memorial Healthcare System implemented an RFID system to keep track of patients throughout the hospital, automatically updating the patient location in the clinical database. It has offered several benefits including decreased length of stay due to triggers that determine if a patient has been in one location too long, patient and staff satisfaction since the location of the patient is readily available, and even increased revenue since co-pays are collected when patients return their RFID badge to registration.

In the hospital setting, RFID-tagged identification cards could serve to authenticate staff for access to the electronic medical record. John Halamka, MD, chief information officer of Harvard Medical School, took this a step further and decided to have an RFID tag from VeriChip implanted in December 2004 to test its use in the emergency setting.¹⁰ He had the device identificiation number mapped to his master patient index number, and plans to study its use for future medical applications. Tommy Thompson, former secretary of Health and Human Services during the George W. Bush administration, has received an RFID implant for access to his medical record.¹¹

A very intriguing implementation of RFID has been its use in the emergency room (ER) at Mercy Hospital in Coon Rapids, Minnesota.¹² Patients whom are identified as vulnerable, in that they pose a threat to themselves or others, were monitored via RFID bracelets in the RF Technologies system.¹³ This system enabled the ER to reduce its need for security staff since radio sensors would automatically lock exits if these patients attempted to leave. Nurses would redirect patients and reset the alarm, but if they could not, security was automatically summoned. There was >$100,000 savings in security guard costs due to a 60% reduction of direct one-on-one staffing. A byproduct of this system was improved privacy since security guards were no longer positioned outside of the door of these patients.

Psychiatric patients in the outpatient setting can also benefit from RFID technology. RFID tags can also be embedded in bottle caps to record when medications are taken from a bottle, creating a compliance record.¹⁴ Since poor medication adherence has been demonstrated to be associated with poorer functional outcomes in patients with schizophrenia,¹⁵ it is obvious that any information that helps the psychiatrist recognize medication noncompliance early will decrease likelihood of decompensation and subsequent hospitalization.

Patients with Alzheimer’s disease living in residential facilities can be monitored to keep track of their whereabouts. Wendy Rogers, PhD, professor of psychology at Georgia Tech, and colleagues at the Aware Home Initiative, use RFID tags embedded in the shoes of senior citizens to monitor their activity level.¹⁶ These data are uploaded to computers and distributed to family members so that they can review their activity remotely. The computers can be programmed to send alerts to loved ones if insufficient activity is detected. In conjunction with the global positioning system-based wristwatches from Wherify Wireless, lost patients may be a less frequent tragic event.

Barriers

Despite the numerous potential benefits of RFID technology, the main source of criticism and likely hindrance to implementation has been the issue of privacy. The primary objection is that RFID tags do not require line of sight to be read, therefore they can be scanned without bearer knowledge and consent. The Rand Corporation did a study replicated at six workplaces on how many companies are without explicit policies on how RFID door access control data were utilized.¹⁷ Parents at Brittan Elementary School in Sutter, California, forced the administration to halt usage of the RFID-based InClass attendance system by InCom due to concerns of privacy.¹⁸

Even RFID has the potential to be “hacked,” as Westhues¹⁹ has demonstrated an ability to “spoof” or pretend to transmit the identification tag. Consumers are concerned about misuse of information in RFID tags, especially active tags which are accessible at longer distances and potentially contain more information.

Conclusion

In the field of mental health, privacy is a cardinal issue demanding sensitivity and attention. Without establishment of trust, the validity of information obtained and ability to effectively work with patients is greatly diminished. Privacy concerns should be addressed along the guidelines of the Electronic Privacy Information Center,²⁰ a public research center in Washington, DC, which has developed these guidelines for appropriate RFID use in healthcare settings. This four-tier framework for RFID regulation of medical information provides for stepwise regulation and use of information.²¹

However, despite the EPIC concerns for permanent “tagging” of individuals, there has been a subculture of individuals who have voluntarily implanted RFID tags for a variety of purposes.²² Amal Graafstra has written a book on how he has used his RFID tags for logging into his computer, gaining entry into his home, and accessing a safe.²³ It seems that with any new technology, the public needs time to understand its benefits and risks to make informed decisions. The advantages of RFID are many, but the market for it and positive public opinion are lacking. RFID appears not to be ready for implementation today.

Disclosure: Dr. Luo reports no affiliation with or financial interest in any organization that may pose a conflict of interest.

References

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21. Rotenberg M. Privacy Implications of RFID Technology in Healthcare Settings. Presentation at Department of Health and Human Services. January 11, 2005. Available at: www.epic.org/privacy/rfid/rfid_ncvhs1_05.ppt. Accessed June 14, 2006.

22. Tagged RFID Implant Forums. Available at: http://tagged.kaos.gen.nz. Accessed June 14, 2006.

23. Amal’s RFID Implant Page. Available at: www.amal.net/rfid.html. Accessed June 14, 2006.