Radiofrequency Identification for Inventory in Neurointerventional Practice

Radiofrequency Identification for Inventory in Neurointerventional Practice Ernest Byers, MA, Max A. Gomez II, Robert M. Sheridan, Nelson W. Orr, Joshua A. Hirsch, MD

Implementations of radiofrequency identification (RFID) systems within hospital settings are not unique or without controversy. To date, little consideration has been given to use of this technology in clinical interventional radiologic practice. The potential financial advantages coupled with benefits to quality and safety and increases in staff satisfaction are considerable. The authors outline these advantages by enabling readers to broadly consider the systemic perspective of implementing RFID technology with an associated vision toward downstream growth. Furthermore, the authors demonstrate the benefits of RFID technology integration in reducing cost and increasing quality assurance and the on-time delivery of services. Implementing RFID requires commitment from frontline technologist staff members to work collaboratively with management and external vendors. Ultimately, the authors believe this technology can positively influence patient care. Key Words: RFID, interventional radiology, medical inventory, patient billing, human factor J Am Coll Radiol 2011;8:191-198. Copyright © 2011 American College of Radiology

INTRODUCTION Radiofrequency (RF) identification (RFID) is increasingly prevalent and applicable to 21st-century patient care [1]. This type of technology and its potential applications are vast. Our patients, members of an increasingly digital and data-based world, experience it throughout their everyday lives. Examples of RFID technology in common use include retail store management (WalMartⴱ) [2], highway toll collection (E-ZPass) [3], professional sports ticketing [4], and the US Department of Homeland Security [5]. Additionally and importantly, several top-tier hospitals and health care systems throughout the country, in varying fashions, have implemented RFID programs. Examples include New York-Presbyterian [6], the University of Chicago [7], the University of Michigan [8], Boston’s Children’s Hospital [9], and Partners Healthcare System [10]. In January 2008, interventional radiology (IR) at Massachusetts General Hospital (MGH) set out to integrate RFID technology with its operational logistics and medical supply patient care practices. Interventional radiology at MGH is a dynamic clinical service. In many ways, it serves as a backbone service, allowing patients timely access to minimally invasive, potentially lifesaving procedures. Manage-

Imaging Department, Massachusetts General Hospital, Boston, Massachusetts. Corresponding author and reprints: Robert M. Sheridan, Massachusetts General Hospital, Imaging Department, 175 Cambridge Street, Suite 200, Boston, MA 02114; e-mail: [email protected]. © 2011 American College of Radiology 0091-2182/11/$36.00 ● DOI 10.1016/j.jacr.2010.09.006

ment often views IR as an engine for generating revenue. This can be brought into particular focus when profit margins and changes to both the internal and external hospital environments preoccupy senior board room agendas. At MGH, the procedural aspect of neurointerventional radiology (NIR) is relatively controlled in terms of case mix, volume, and supplies. As well, it is as an area that interfaces and shares resources with other practices, most often vascular IR and the operating room. The division is composed of several key staff role groups: physician providers, procedural nurses, and technologists. Technologists play a salient role in inventory management, spending considerable time working interprocedurally in the operating room and working intraprocedurally across multiple interventional procedure rooms. These staff members regularly use, transport, and maintain millions of dollars of on-hand inventory assets (highly specialized catheters and microcatheters, wires and microwires, coils, stents, liquid embolic agents, and other implantable devices). Neurointerventional radiologic technologists were determined to be perfect champions or “end users” of RFID in IR at MGH. With their enthusiasm and willingness to embrace new technology, the use of RFID led to less time clarifying, searching, and verifying inventory items used for patients (see Figure 1). This further led to more time spent attending to the care of patients and the maintenance of practice operations. For technologists, that results in increased job satisfaction, and for senior man191

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Fig 1. MGH NIR: Inventory Management Practices: Bar Code vs RFID.

agement, it translates to increased cost savings and revenue-generating potential. In subsequent sections of this article, we review various aspects of why RFID technology is particularly adaptable for inventory management as well as for patient billing within a large, modern-day hospital system. Our experience indicates that the benefits of RFID technology clearly have the potential to outweigh initial costs.

INSTITUTIONAL BENEFITS, BARRIERS, AND APPLICATIONS The adoption of RFID technology within hospitals for the purposes of inventory management has generally lagged behind other industries for reasons ranging from cost (initial investment, total cost of ownership, and speed of payback) to perceived benefit. After pure cost,

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the most significant barrier to the adoption of RFID technology is that it requires a significant modification in the traditional investment strategy of most hospitals, including MGH. For most hospitals, the investment strategy is heavily focused on staving off or addressing the inevitable depreciation of both the physical plant and the capital equipment within it. In this common scenario, hospitals may be unable to break even or budget to scrape by with razor-thin margins. Moreover, the typical capital investment pool, from which these investments must be funded, are often inadequate. As such, it is no surprise that when confronted with the choice of purchasing an “unproven” technology such as RFID and replacing an end-of-life revenue-generating CT scanner, the choice is seemingly easy for hospital leadership. In other words, capital dollars are often first allocated to the acquisition of devices that will improve the efficacy of clinical practice and generate revenue and only secondarily to improve the effectiveness and efficiency of the business and IT practices that support clinical practice. As a result, many of the IT systems on which a typical hospital relies to support its clinical practices can be outdated and not well integrated. This is in regard to both system-to-system and clinical workflow integration. This is unfortunate because the ultimate and ongoing benefits of implementing RFID technology are seen when RFID technology is integrated with existing IT systems that support the clinical practice [11], to effect more efficient inventory replenishment and more accurate charge capture. As such, those who have managed to convince their organizations to make the initial investment in some form of RFID technology for inventory management seldom realize the entire or ultimate benefit from their investment. The benefits typically realized by adopters of RFID technology are most often one-time, or isolated, cost savings associated with a one-time reduction in the carrying cost of on-hand supply inventory. Seldom realized is the benefit to the increased accuracy of charge capture. Compared with the current NIR inventory management system, bar coding, over a 10-month implementation period, NIR practice saw total charge capture rise by roughly 20% or $60,000 per month. This exceptional increase contributed to a return on investment that covered at least 4 times the cost of monthly operating and lease expenses of the RFID tracking cabinets. The use of RFID technology to manage and track supplies also affords users a more accurate and timely understanding of the inventory required of a given supply to support the clinical practice. Once the par levels for the supply are adjusted to reflect the actual needs of the clinical practice, the savings associated with that adjustment are by definition demonstrated only during the fiscal period in which the adjustment occurred.

The ultimate benefits of implementing RFID technology are achieved when the technology itself is leveraged to sustain the aforementioned improvements by automating the communication between the hospital and supplier and then in turn assigning the use of a specific item to a specific patient for safety and billing purposes. Drawing on the principles of efficient consumer response management [12], first developed by the grocery sector of the food industry, RFID enables this automated communication at the point of service or sales. Take for example a simple transaction at the grocery store. You, the consumer, walk to the checkout counter of your local supermarket. Information regarding each item from your shopping cart that is scanned at the point of service or sales is sent via electronic data interchange to the supplier. This allows the grocer to simultaneously notify the supplier that replenishment stock is needed and secure payment for the item from you, the customer. Such a situation is mutually advantageous for both the supplier and the retailer. The supplier, who controls the availability of the product, can more accurately forecast the next day’s shipping requirements. In turn, the retailer has a better understanding of what items are selling and, as a result, begins to adjust existing stock levels, diversify existing product mixes, and add new products, giving that supermarket a competitive edge with respect to those stores still purchasing stock in bulk. The efficient consumer response model translates well into health care organizations using RFID technology. For example, a patient is undergoing a procedure. Via an interface with the hospital’s admissions, discharges, and transfers system, and an RFID supply cabinet, the patient’s demographic profile is pulled up on the RFID cabinet. As products are removed from the RFID cabinet, two things happen: (1) products removed from the cabinet are associated with the patient via an interface back to the admissions, discharges, and transfers system for safety and billing purposes, and (2) replenishment quantities for the products used are sent via interface to the hospital’s purchasing system. Because of the associated automation of RFID tracking, NIR practice experienced labor cost savings equivalent to approximately 3 hours less time spent per day on manual processes, which equates to a 30% reduction in technologists’ non-value-added time per day. Moreover, key staff members can receive customizable automatic expiration reports on products due to expire; for example, the NIR inventory management technologist will receive alerts 60 days before product expirations, coinciding with vendor consignment agreements and reduction of risk to patients. Similarly, IR administrative directors can receive product expiration reports closer to the date of expiration, for example, 7 days, to enforce compliance. Over the course of our 10-month period of

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implementation, no expired products were used, a reduction of 8% risk, for at implementation launch, 8% of NIR inventory had expired or was dangerously close to expiration. THE VISION OF RFID AND THE STRATEGY FOR IMPLEMENTATION Radiofrequency identification typically contains two components: the first is a circuit used for storing and processing data and tuning and adjusting RF signals. This is generally embedded into an “RFID tag.” The second component in RF technology is an antenna that receives or transmits an RF signal depending on whether the system is configured as a passive or an active system. There are 3 types of RFID tags. The first type is defined as passive technology; these tags emit no signal, and they are designed to receive a signal when pinged by an external antenna that sends an outbound RF signal. These types of RFID tags are commonly used in shopping centers and department stores to alert clerks of pending shoplifters. The second type is classified as active tags; these tags are battery powered and emit a signal that is captured and processed by an antenna that reads the RF signal. These types of tags are commonly attached to aircraft, mobile navigation, and communication devices, such as the BlackBerry and iPhone. The third type of tag is a battery-assisted passive tag capable of sending a stronger signal to the receiving antenna compared with traditional passive tags. Radiofrequency identification systems applied to inventory management within the health care industry are most often passive RFID tags in the form of labels. These labels get applied to specific products to be read by the said antenna and are nearly paper thin, with dimensions in the range of approximately 2 ⫻ 2 cm [13]. The modern era of “better inventory management” in IR at MGH developed in November 2001, when a bar code system was applied to manage the hundreds of medical and surgical supplies required to treat patients with minimally invasive endovascular techniques. This bar code system advanced the division’s ability to make datadriven decisions regarding business intelligence, specifically related to inventory management. The database was able to capture such metrics as on-hand inventory assets, receiving, utilization, and expiration dates of medical and surgical supplies. There was initial success, with a one-time reduction in on-hand inventory value or “carrying cost” and the ability to set appropriate par levels, which ensured vital supplies remained in stock for physicians to treat patents. Furthermore, the data captured by bar code enhanced management’s ability to accurately budget supply accounts for upcoming fiscal years. These early

successes were considered significant accomplishments at the time of implementation. Although the system offered clear advantages to traditional logs and manual tracking systems, limitations of the bar code system were soon realized and needed to be monitored and controlled. Inherent to any bar code system is the heavy reliance on the human factor (HF) or staff interface to maintain system accuracy. Scanning bar code labels and the arduous manual cyclical counts required to reconcile use against actual on-hand inventory count are two major challenges in sustaining accuracy within this system. Moreover, the amount of staff training required to sustain a bar code system was time-consuming and fraught with flaws associated with the HF (eg, staff compliance with scanning products intraprocedurally). In addition, the lack of real-time product location and real-time inventory value presented its own set of challenges for management. These limitations were overcome with a lot of manual validation and rework, which led management to investigate alternative systems to manage the multimillion dollar supply chain in IR. RFID technology presented several opportunities for managing medical and surgical inventory in IR, especially considering the above-described tribulations associated with the bar code system. The perceived potential value added by RFID technology derived from its ability to solve many complex operational and clinical workflow issues. Real-time inventory value, ease of tracking product use, increased accuracy in managing expiration dates, and up-to-date product locations were all enhanced by applying RFID technology. The HF could be significantly improved, although not completely removed, compared with the bar code system. Consideration of the HF returns to prominence with RFID during tasks relating to initial product intake (eg, affixing RFID chips to products) and during tasks relating to erred product use (eg, trashing items and removing them from the patient’s accession). After enjoying the initial gains associated with bar code system implementation, it became clear that the system was in more ways prone to error and required more time associating products tracked with patient records and where the use of products needed to be manually associated with patient encounters during certain steps of the process. To vet the RFID technology fit and test HF assumptions, radiology leadership set out to design an approach that would test the application of the technology to the “real world” environment. Ideally, such an approach would set the stage for a scalable rollout, allowing the expansion of the technology across the 7

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divisions within our IR department (ie, starting small and proving the concept). The design of the application was triphasic. In the first phase, 5 cabinets were embedded within one of the two NIR suites to evaluate the impact of the technology against the current workflow. Initially, the highest unit cost items were identified and housed within the RFID-enabled cabinets. The rationale was to both track expensive, generally highly used products and to mitigate the possibility of being caught intraprocedurally without the necessary medical devices to provide care while preventing expired products from being implanted in patients. Neurointerventional radiology treats intracranial aneurysms that come in a variety of shapes and sizes. To be adequately prepared for situations both foreseen and unforeseen, a hospital will typically stock a broad range of coil types. The initial product load revealed that despite the bar code system described above having been in place for 7 years, 10% of the on-hand detachable coils were dangerously near to or had reached their identified expiration dates. Over the next quarter, the division tracked the use of implantable coils. The use data were then analyzed, enhancing the ability to make “business intelligence” or data-driven decisions in reconciling appropriate par levels of myriad types of coils required to treat aneurysm patients. The additional benefit realized was high staff satisfaction and interest. The new workflow was simplified; technologists simply identified and then picked the patient from the cabinet’s work list, pulling items from the cabinets and placing them on the sterile field. This eliminated the need for manual cyclical counts scanning bar codes and many hours of training. The benefit of being able to locate any product in the cabinets in seconds, saving both time and unnecessary stress, soon became obvious to all involved. Phase 2 of the implementation process included two distinct milestones: the expansion of the number of cabinets into the second NIR suite and an inventory management interface with PeopleSoft (Partners Healthcare’s enterprise resource planning system).

The expansion allowed near comprehensive tracking of much of the NIR inventory by increasing the cubic inches of RFID-enabled storage. Together with the PeopleSoft interface, this provided real-time and comprehensive snapshots of the on-hand inventory value in parallel with automatic reorder messages sent to create purchase orders with external vendors and medical and surgical supplies on the basis of on-hand inventory par levels. Phase 3 completed the “electronic round-trip ticket” or efficient consumer response management, previously described associated with the food industry. This allowed automatic messages of inventory used by patient or case to be sent to the department’s radiology information system for delivery to billing and insurance agencies, ensuring accurate capture of items used by date, patient, and examination type. This resulted in a reduction in time spent identifying and confirming chargeable devices for patient insurance. To bridge the gap from concept to reality and move between the 3 phases of implementation, sound project management principles were needed. PROJECT MANAGEMENT OF THE IMPLEMENTATION AND INTEGRATION Project management of the implementation and integration of RFID included a close watch for data congruency and adherence to the frontline and end-user perspective. Two main themes of the project were synchronicity of data and staff comfort. These two themes were and still are important to the sustainment of this technology. Many organizational change efforts discuss “buy-in” to change; for the project phases in our RFID integration and implementation, this was no different. The initial buy-in from NIR technologists was high because of the novelty of RFID as well as the ease of use with patient workflows and the automatic deduction of inventory from product counts. Technologists did experience what we would term a natural trepidation when

Table 1. Initial staff reaction to use of RFID cabinets Response Comments Strongly favor Would make life easier for everyone. Strongly favor Increases efficiency and accountability for product usage. Strongly favor Need to track expensive items. Favor Keeping track of inventory on an individual patient level. Direct links to billing and purchasing. Note: Question 1 (Likert-type scale) was “What was your initial reaction to use of the RFID cabinets?” Actual staff responses are included. RFID ⫽ radiofrequency identification.

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Table 2. Perceived strengths of RFID cabinet use Comments Keeps inventory locked, and keeps track of inventory. Ability to increase efficiency by reducing the number of mistracked products. Ability to increase quality and safety by electronic tracking of expiration dates and lot numbers. Have been told that data is good. Keeping track of inventory, notice of expired and about to expire product. Note: Question 2 (open ended) was “What do you think are the strengths of the using RFID cabinets?” Actual staff responses are included. RFID ⫽ radiofrequency identification.

first introduced to the new system. The implementation and integration approach included reassurance through enhanced training, feedback, and input in management decision making. The NIR technologists were trained in tasks relating to cabinet access, patient selection (on a digital workflow), removal of items, returning of items, affixing RFID tags to items, and stocking the cabinet. Between phases 1 and 2, feedback was collected through an anonymous survey using our adapted Likert-type scale (“strongly oppose,” “oppose,” “neutral,” “favor,” and “strongly favor”) and open-ended questions. Responses to and comments from this survey are contained in Tables 1 to 3. The survey demonstrated general acceptance of the new technology and workflow. The main area of concern was the physical location of the cabinets, which in phase 1 were located outside of the procedural rooms in which the inventory was used, necessarily resulting in staff members’ having to walk in and out to get material. This issue was addressed through innovate installation of an external bar code reader on the RFID cabinets, ensuring less back-and-forth motion and walking distance for technologists and unexpectedly additional tracking of inventory. Support from the lead material handler in the technologist group was of further importance to project integration because his or her role and workflow were affected the most. Significant upfront inventory reconciliation and tabulation needed to be, and was, performed by the lead material handler to ensure synchronicity of data. This included the list of synchronicity and reconciliation tasks contained in Table 4. These were tasks he or she

and probably no other member of the hospital could perform for NIR. The completion of the synchronicity and reconciliation tasks ensured the hardware and software architecture for inventory management workflow integration with RFID. This upfront attention to detail led to the increased labor efficiencies discussed earlier. The project implementation and integration could only be as successful as the end users’ acceptance, maintenance, and use. Consideration for RFID integration must be entertained at all levels of the organization, and its applicability must fit with operational workflow, end users’ compliance, and the institutional vision for patient volume growth. FACILITATION OF THE FUTURE OF NIR PRACTICE The year 2010 began with health care reform becoming law in Washington. Few certainties exist in health care today. Perhaps the greatest certainty is that the unchartered road ahead will require better efficiencies to allow for the practice of high-quality health care as we have come to know it. The IR division at MGH has made real-world decisions to improve our operation. As with many such programs, the effort has required redirection at various points. The bar code system that was put in place in 2001 represented a major advance over traditional inventory management systems. At the time, there were those within our own system confident that this revolutionary concept would “never work,” that the

Table 3. Perceived weaknesses of RFID cabinet use Comments There is the potential, if we come to rely on the technology too much, to mistrack products between patients when more than one case is going on. Having to leave exam room to get additional product. Labeling product with RFID stickers on site, it would be nice to have cabinets in rooms. Note: Question 3 (open ended) was “What do you think are the weaknesses of using RFID cabinets?” Actual staff responses are included. RFID ⫽ radiofrequency identification.

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Table 4. Reconciliation and synchronicity Synchronicity Task Determining location, accessibility, and quantity of RFID cabinets Purge expired product and outdated product currently occupying physical space Determination of which product will be tracked by RFID

of data tasks Reconciliation Task Reconciliation of inventory spreadsheets (RFID vendor and institution) Ensure tight control of spreadsheet (risk of deletion or edits of extensive numerical identifiers) Cross-reference common identifier and catalog number with item description, item manufacturer, item pricing, item codes for billing and charging, item par levels (minimum quantity and maximum quantity)

Complete inventory count of all products Note: RFID ⫽ radiofrequency identification.

seeming decrement in the human interface would negatively affect the artistry providers achieved routinely in the interventional workplace. Perhaps not surprisingly, the bar code system brought with it clear and reliable improvements. As detailed above, these improvements were simultaneously limited by the constraints inherent in any such system. In 2008, departmental leadership endeavored to evaluate whether theoretical advantages of a more robust RFID system might enable systemic improvements through operational efficiencies. The NIR division represented an opportunity to test the thesis. Realities of practice were every bit as challenging in NIR as one might expect, with physicians’ reliance in life-and-death situations on the correct products being rapidly and reliably available for them to use. This project, like almost all others, has a timeline and life expectancy. At various phases, if it were not working, it was distinctly possible that management might pull the colloquial plug. There are many ways this RFID effort could have failed. Examples include failures to (1) achieve the expected monetary savings, (2) see improvement in inventory management, and (3) successfully incorporate and thereby obtain buy-in from technologist staff members. One can further imagine the chilling effect failure to provide reliable access to necessary inventory to the NIR physicians would have had on this project. In 2010, the NIR division expanded rollout of this technology to include more actual RF devices, helped create modifications in the actual product (such as the external bar code), and expanded to include a greater quantity of inventory. Although the situation in NIR is a unique microcosm within the broader world of patient care, we believe it nonetheless provides helpful lessons and insights for future health care sites for potential rollout of this technology. Our effort has yielded clear advantages to the NIR

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