Exploring the application opportunities of RFID in an Elderly Center [004-0296]

Yuyu Zeng 1 and T. L. Lau 2

1M.Phil. Student, Department of Industrial and Manufacturing Systems Engineering, The University of Hong Kong, Email: h04yuyuz@hkusua.hku.hk 2Associate Professor, Department of Industrial and Manufacturing Systems Engineering, The University of Hong Kong, Email: tllau@hkucc.hku.hk

ABSTRACT

By providing the identity of items in a supply chain in a timely and automated manner, Radio Frequency Identification (RFID) technology offers great opportunities to innovate and improve operations in various industries. In healthcare settings, human intervention and the characteristics of clinical operations make system requirements different from those in supply chain management. Special issues from product development to technology acceptance need to be considered in system deployment process. In this paper, we explored potential RFID applications in an elderly center by conducting site visits, interviews and prototype test. We further investigated the obstacles which should be removed before system implementation. Expected benefits of our RFID solutions and challenges in the system design were discussed. Recommendations for future research were also identified.

Keywords: RFID; Healthcare operations; Human factors; Product development; Technology acceptance.

1. Introduction

Health care services were defined as all medical support services, such as nursing, provision of food and beverage, ward service, counter service, and other ancillary services [1]. Providing health care services is an information intensive process. The information required from a particular resident to the medical technology and system is highly specialized and sophisticated, requiring close communication between many sectors involved in the service providing process. Therefore the use of information technology in health care is essential for achieving improvements in health care quality, efficiency, and cost-performance [2]. Health information technology refers to the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision-making [3]. The use of information technology in health care industry is focused mainly on recording and retrieval of medical records, resident registration and payment transactions [4, 5]. Several researchers have explored how to leverage IT to facilitate home care for elders. Mynatt E.D. et al. introduced the concept of a digital family portrait that gathers information from sensors in the home to provide qualitative visualizations of a senior family member’s daily life [6]. Mann and Helal presented their vision of using smart phones both as remote control devices and as elders’ intelligent companions offering advises, reminders, warnings and calls for help [7]. Pollack M.E. et a l . investigated how robots could assist elders in their daily activities [8]. Though many attentions have been put into at-home settings, the potentials of RFID have not been investigated adequately. Also the situation in Hong Kong is very different from the patterns in other countries. The elderly are highly respected in Asian cultures. It has been recognized as a tradition that aging parents should live with their descendents. In the

recent decades, it is becoming more and more difficult for families in Hong Kong to keep this tradition. Most families do not have enough space to accommodate three or more generations to live together. Another problem arises with the increasing longevity. How could retired senior citizens take care of their elder parents if they are not able to live alone by themselves? Not to mention the special care needed for age-related challenges such as dementia and paralysis. It is therefore not surprising that many people send their parents to various professional care-service providers. The main purpose of this study is to identify potential RFID applications in elderly care settings. We will also discuss factors that could influence the adoption of RFID in an elderly center, and obstacles which should be removed before system implementation based on a case study. 2. Case study The case study was carried out in ABC Elderly Center in Hong Kong. It serves approximately 150 residents. We did this study to examine their current care delivery operations, identify factors involved in the technology acceptance process and to further propose RFID improvement solutions for them. From June t o October 2005, we conducted a series of site visits to this elderly care center. We did interviews, direct observations and set up a pilot project in the field to uncover their needs, current practices, and rooms for improvements. 2.1 Methodology Interviews: We invited four caregivers for interviews, all female, including the chairperson of the elderly care center, the manager and two nurses. This center has a very harmonious atmosphere. The chairperson visits the residents twice a day, so she understands each resident’s conditions and difficulties at first hand. The manager and nurses are the direct care-service providers. We conducted in-depth interviews with them to understand their current practices and needs. Observations: We visited the elderly center twice to observe the residents activities in their daily lives. We recorded these activities with appropriate documentations so that potential improvement in the work flow can be identified. We also observed the behavioral patterns of the residents and their reactions towards new devices. Prototype test: After these pre- implementation site visits, we decided to set up a pilot study in ABC Care Elderly center from 12th to 13th in October 2005. In this project, the performance of passive RFID tags to be worn by human beings in healthcare environment was examined. After this pilot study, both nursing staff and elderly residents got a better understanding of how an RFID system works. 2.2 Their current problems 2.2.1 Problems in preventing residents from wandering away ABC Care Elderly Center installed an electronic code lock system on the main entrance door. Only staffs who knew the code could enter and exit the center freely. Others such as the elderly residents and visitors who wanted to open the door had to ring a bell at the

entrance to get the reception clerk’s permission. The entering and exiting records of each resident and the visitors were kept in a log book. This work consumed a large amount of time and effort of the reception clerk. In ABC Care Center this problem is especially serious because the clerk also acts as the manager of center. She told us the biggest problem they had was sometimes the elders just wandered away without anybody’s notice. She said some elderly residents learnt how to open the entrance door by observing the clerk’s operation. When no one is watching, they were able to unlock the door by themselves and leave the center unnoticed. It would lead to serious results especially for those residents having Alzheimer's dementia. 2.2.2 Problems in medication administration process Most elders need to take medicine regularly during the day. In ABC Care Center, a nurse is in charge of medication administration process for about seventy residents on each floor. The nurse allocated each elder’s medicine according to each prescription, and put them into individual plastic bottles labeled with residents’ names. She then put these bottles in a basket and carried this basket of medicine to perform the treatment. This method was simple and convenient for pills that can be counted. However for liquid medicine such as eye drop which does not allow easy apportioning, it would cause troubles. The nurse might forget whether she had or had not treated he residents as there is no obvious visual feedback. Or she had to record it manually after finishing each job, which was troublesome, error-prone, and time-consuming. 2.2.3 Problems in food provision for diabetes residents Many people enjoy sweet drinks, some kind of snacks containing sugar, between lunch and dinner or after dinner. Residents are provided with these snacks apart from ordinary meals. Since some elders had diabetes, snacks free-of-sugar should be given separately to them. According to our observation, in ABC Care Center this separated service was carried out relying on a nursing staff’s memory. Though stored in different pots, food with or without sugar was served at the same time to all residents. Nurses distribute the food upon their recognition of which residents should have which kind of snacks. We noticed even in such a short observation period that diets containing sugar were distributed carelessly to residents having diabetes. Although the nurse realized the mistake and stopped it in time, it is possible that the fault remains unnoticed and terrible accidents would happen. 3. Application of RFID and expected benefits 3.1 RFID opportunities The technology of RFID is recognized to be very useful to simplify and improve the service delivery process in health care. The main benefits of applying RFID in health care are expected to be the improvement of residents’ care, costs reductions and assets utilization. Correa et al. listed several operations in health service which can be improved from the viewpoint of lean manufacturing [9]. We developed the following list according to the characteristics we observed from the elderly center.

Wastes Definition Specific problems in Health care industry

Overproduction Producing more than the customer needs right now

- Pills given too early to suit staff schedules rather than the customers’ schedules.

Redundant Motion

Movement of people that does not add value

- Searching for elderly residents, physicians, documentation, supplies, equipments, etc.

Prolonged Waiting

Idle time when material, information, people, or equipment are not ready

- Residents waiting for bed assignments, testing, treatment, and discharge.

Redundant Processing

Effort that adds no value from customer’s viewpoint

- Excessive paperwork - Unnecessary procedures

Excessive Inventory

Excessive materials, parts, or products on hand than the customer needs right now

- Bed assignments - Pharmacy stock - Lab supplies - Specimens awaiting diagnosis

Defects

Work that contains errors, rework, mistakes or deficiencies

- Residents wandering away - Medication error - Missing documentations - Errors in food provision (food goes to

wrong resident) Table.1 health care operations that can be improved by using RFID

3.2 The RFID solutions 3.2.1 System requirements

· A wireless network which covers the whole elderly center; · Antennae: at least two antennae are necessary at each gate; · Passive tags to be embedded in residents’ daily belongings; · Specially designed PDA: for nurses to improve the effectiveness in providing

health care services; · A computer with an integrated database which contains residents’ personal

information, their medical prescriptions, etc.

3.2.2 Preventing elders from wandering away Elder residents wandering away without notice is the most concerned problem in ABC Care. To eliminate this problem, we suggest each resident wear an RFID tag, the placement of which will be discussed later, and the gate is equipped with antennae. An alert will be triggered once an unauthorized case turns up. The alarming conditions can be set by system administrators. For example, the manager can choose to be informed when someone who does not carry a tag but opens the door. This proposal is to prevent residents who take off the tags and leave the center. Alternatively she may want to be alerted when an elder resident exits the gate without permission by detecting his tag through antennae.

3.2.3 Medication administration Our RFID solution for medication administration requires a special designed PDA for nursing staff, which combines with RFID reader and is able to update data such as resident’s medication prescription and medicine taking records with the host computer system through the wireless network. In medicine administration process, a nurse carries medicines and the PDA. She will scan a resident’s tag, and find the records and status on the PDA before treating residents with pills or liquid dose. If the resident has already taken the dose, this PDA will give out a signal to alert the nurse. Otherwise, the nurse will feed him according to his prescription. After this scanning the resident’s medicine-taking status is updated. On the other hand, if the nurse forgets to feed a resident, and the status is not updated for a certain period behind the schedule, the nurse will receive a reminder from her PDA about this mistake. Considering the current lack of tags on the unit dose drugs, medicine allocation job could still be done by manpower, and the prescriptions displayed on the PDA can act as a double check. In the future, the whole medicine administration process could be done in a more secure manner, ensuring the five rights of medication administration process, namely, right medication, right dose, right time, right resident, and right route. 3.2.4 Food provision Similar process can also be used in provision of meals and snacks. After the nurse’s PDA detecting a resident’s RFID tag, his personal record will be shown on the screen. If this resident has diabetes mellitus, nurses will be reminded not to serve food containing sugar. 3.3 Expected benefits of using RFID

· RFID tags allow scanning without direct line-of-sight through clothing or blankets for less resident disruption;

· Robustness: The tags are waterproof and can endure much more rough handling situations compared with traditional bar-coded tags;

· Ability in monitoring and tracking unauthorized people movement in real- time; · Easy access to resident’s medical records through his RFID tag; · High reading speed brought by significant reading range and the ability to reading

multiple items simultaneously; · Safer medication administration performance; · Fewer accidents in provision of meals and snacks.

4. Factors influencing the adoption of RFID In this section, we discuss the factors from technology itself, the organization and external environment that have impact on the adoption of RFID in an elderly center. A framework description is given and it is followed by discussions of these factors through our case. An innovation is a good service or idea that is perceived by someone as new [10]. The innovation we discussed in this paper is RFID. The factors that contributed to the successful innovation adoption in specific industries may apply differently in health care.

Health care industry has its unique features, which make the adoption of technology in this field different from other industries such as logistics and manufacturing. 4.1 Innovation characteristics The rates of a successful adoption are affected by several innovation characteristics. Roger identified five characteristics. They are: the “relative advantage”, “compatibility”, “complexity”, “trialability”, and “observability” [11]. Two further ones were figured out by Herbig and Day as “cost” and “perceived risk” [12]. Relative advantage: This is the degree to which an innovation is perceived as being better than the idea or product it replaced. The relative advantage of an innovation is positively related to its adoption rate. The degree of relative advantage is often expressed in economic profitability, in savings in time and effort, in status giving, etc. In our case, the relative advantages refer to savings in time and effort of health care service providers, improved health care service, and economic profitability in the long run, considering error costs and human power cost being reduced. Compatibility: This is the degree to which an innovation is perceived as consistent with the existing values, past experiences, and needs of potential adopters. It is positively related to innovation adoption success rate. In ABC center, the application of RFID simplifies the procedures of employees and releases the workload of them. Since the RFID solution will be developed to fit their actual needs and existing settings, it is considered compatible with the current practice. Complexity: This is the degree to which an innovation is perceived as difficult to understand and use. It is negatively related to the adoption of an innovation. Although the technology of RFID itself is not easy to be understood by the users, the procedure of using it is fairly straight forward for employees and residents in ABC elderly center. Trialability: This is the degree to which an innovation may be experimented with on a limited basis. It is positively related to the adoption rate. Innovations that can be tried on the installation plan will generally be adopted rapidly, because this shows fewer uncertainties for the adopters. In our study, we have done pilot tests in-field which served this purpose. This is an indispensable step to persuade organizations in health care industry to adopt a new technology, even if the experiment is not set up at their own location. Observability: This is the degree to which the results of an innovation are visible to others. The easier the results from an innovation are observed and communicated to others, the higher its adoption rate will be. During our pilot project, the employees and elderly residents gained first-hand experience with RFID technology, and how it would facilitate their daily work and life. Cost: The less expensive the innovation is, the more likely it will be quickly adopted and implemented. Here the costs include hidden ones such as the effort put in training the

employees and residents, as well as having the organization adapt to the environment after implementing the innovation. Perceived Risk: In considering the adoption of an innovation, the customer is faced with two types of risk. One is risk of failure or disappointment with the innovation, and the other one is the opportunity cost of rejecting an innovation that would be highly profitable. The perceived risk of an innovation is negatively related to the rate of innovation adoption. One of the methods to reduce these risks is to involve both employees and residents in the design and implementation process. User involvement helps in identifying key requirements and improving design, thus reducing the risks and increasing the rate of adoption. Several empirical researches have demonstrated the crucial importance of user involvement in the implementation of technology to the health and well-being of end users [13, 14]. In our study, the pieces of RFID equipment were not primarily designed for health care use. The absence of user-participation in products design process made them not exactly suiting an elderly center, which later impeded the potential quick adoption process. 4.2 Organizational characteristics Financial issues: organizations which have adequate financial resources are more likely to afford the latest equipment, given that new equipment is probably more expensive. Knowledge: The adopters need to understand and spreading necessary knowledge to use an innovation within the organization properly before making up their mind. For example, the manager and nurses, as well as residents in the elderly center need to understand how RFID will help them and what are its advantages and disadvantages in general. If an adequate level of understanding is not obtained before the decision process, the innovation is likely to be rejected. 4.3 External factors Influence from suppliers: In our case, ABC center looked at the technology from their existing demands instead of getting pushed from the vendor. They were therefore not much influenced by the technology supplier. What the supplier may influence on the organization was the knowledge management, which we have discussed earlier. Influence from other industries: As we discussed earlier, health care industry has its unique features. Successful innovation adoption examples from other industries do not necessarily influence adopter’s decision. However, they may raise people’s interest toward this innovation through media or other channels. Government and legislation: Government and legislation have great impact on health care industry. Competitor/ Early adopters: If an RFID system has been successfully adopted by their competitors, the organization will also be stimulated by the market force.

Factors Impact on adoption Relative advantages Highly positive Compatibility Medium positive Complexity Highly positive Trialability Highly positive Observability Highly positive Cost Highly negative

Innovation characteristics

Perceived risk Highly negative Financial issues Highly positive

Organization characteristics Knowledge High influence Influence from suppliers Low influence Influence from other industries Low influence Government and legislation High influence

External factors

Competitor/ Early adopters High influence Table.2 Summary of factors’ impact on adoption of new technology

5. Test results discussion 5.1 Project objectives

· To examine the performance of passive RFID tags worn by human beings; · To explore a feasible facility layout, including tags and antennae placement at the

gate to achieve automatic and highly accurate resident identification; · To show the nursing staff and elderly residents how an RFID system really works

to improve their living and working environment.

All the RFID related equipment we used in this project were from Alien Technology, including one reader (ALR-9780), two kinds of antennae, a linear-polarized antenna A1 (ALR-9610-AL) and a circular-polarized antenna A0 (ALR-9610-BC), and tags (ALL-9239 Squiggle). For the privacy concerns, we gained permission from all the senior participants’ family members before inviting them in this field test. 5.2 Test results and analysis We set up two antennae at the gate, facing each other. One is a circular-polarized antenna and the other is a linear-polarized antenna. Seven residents were invited to participate in our tests. In the first part test, each participant wore one passive RFID embedded wristband on one of their wrists. In the second part tests, we did the tests ourselves by wearing tags on different parts of our body in order to locate the optimal placement of tags and antennae in this RFID system.

5.2.1 Part Ⅰ Evaluate reading accuracy We first turn on the linear-polarized antenna solely, and then the circular-polarized antenna solely. In the third section, we turned on both antenna which were faced each other. The detected rates of RFID tags are fairly low in this part of test. When only one antenna was turned on, the accuracy is no more than 50%. While turning on two antennae, the accuracy is higher. It was 80%. Unfavorable results were caused by several reasons. Comparatively short intervals and the inactivity of the residents might lead to the situation that sampling size was not large enough for accurate analysis. Secondly,

because both height and orientation of tags could affect the reading process, the residents’ attitude and walking postures accounted partly for this problem. They did not necessarily put their wrists beside the trunk when passing the gate. Some even hid the tags from being detected intentionally. 5.3.2 Part Optimal positioning of antennae and tags In this part of test, we tried tag placement at four different parts on the wearer’s body, respectively, the collar, shoulder, outer side of a shoe, and at the lower beam of a wheelchair. We adjusted antennae accordingly in each tag placement to get the closest distance between antenna and tag. Both two antennae were on in these tests. The results are listed in Table.3. At the end, we found that the best system performance could be realized when tags were positioned at the outer side of shoes.

Tag placement Tag orientation Overall accuracy Left shoe outer side Horizontal 100% Right shoe outer side Horizontal 100%

Wheelchair Horizontal 100% Left shoulder Vertical 96.7%

Right shoulder Horizontal 53.3% Right collar Horizontal 100% Left collar Horizontal 90%

Table.3 Results of Part II test When sticking tags at wristband, collar and shoulder positions, system reading accuracy was fairly low. This result was caused both by tag wearers’ conscious and unconscious behaviors. When the residents felt reluctant to be tracked, he or she would prevent the tag from being detected by holding it with the other hand or hiding it behind the body. In our tests, antennae were adjusted to heights according to tag placement on an average male resident with stature between 160cm to 170cm. Once the attendance’s stature exceeds this range to some extent, the reading accuracy will drop. Tag wearer’s walking posture also affect the test accuracy. When the tag was worn on the wrist, the orientation of the tag would vary considerably. On the other hand, reading accuracies w ere much better and reached 100% when tags were stuck to the outer side of shoes or at the lower beam of a wheelchair as the orientation of the tag remain unchanged. No matter how different the walking postures are, the orientation of shoes remains more or less parallel with the antennae. The problem with RFID unfriendly material such as the metal used in the wheel chair was not observed in our test. According to this observation, we suggested that the best arrangement was to stick tags to the outer side of shoes, and place antennae at the height close to the ground. 6. Future work 6.1 Tag design for the seniors The RFID tags we used in the test were designed for mounting on pallets or cartons, where the height and orientation can be easily controlled. Since human body has a wide range of movement and the orientation of the tag will be difficult to control, system

reading accuracy was much lower in our test than that obtained from warehousing operations. Therefore the most urgent task before applying RFID technology in health care settings is to design tags and hardware which are suitable for human use. Another factor is user’s perception. Because one of our ultimate goals is to save manpower in elderly care system and streamline the automatic care-service providing process, user’s perception has a strong influence on technology adoptions. The nurses at ABC Center worried that wearable devices would not be appropriate for elders, because some of them would forget to put on or even destroy such devices. Some researchers also showed that devices could cause users to feel ashamed and powerless, and might contribute to late- life depression [15]. However there are many examples of elders consistently wearing some artifacts, such as wedding rings and wristwatches. We therefore believe that by taking emotional considerations into the devices design process, these devices could be accepted by the users. 6.2 Interface Design for the employees Since the devices are operated mainly by the employees of a health care organization, the product should also be designed on their side. For example, a handheld reader needs to be easily carried along, and its reading range should not bring problems such as misreading and other tags interference. Another important issue is how to design the most appropriate interface between technology equipment and human beings. This is directly related to service quality. Lin et al. did an experimental study in the work of applying human factors engineering principles to the design of the interface of an analgesia device. The results showed that the new interface led to elimination of drug concentration errors, and reduction of other errors [16]. 6.3 Communication between RFID tags and suggested PDAs We have proposed special designed PDAs for improving nursing work. However it would cause problems if tags were stuck to the wearers’ shoes as suggested. Since PDAs are handheld devices, this arrangement would make the communication between tags and PDAs difficult. Not only that. The shoe is not worn by the resident all the time (when he is on the bed or sitting). Also, a resident may wear other resident’s shoes, so the identification will not be correct. Further work should be done on these questions. 7. Conclusion In this study we have explored potential RFID application opportunities in an elderly care center to improve their service performance. Based on the technological studies, we have identified a way to improve the reading accuracy of RFID when the tags are placed on human bodies. We further proposed that people need to consider not only the technological issues, but also to consider ergonomics issues as well as the organizational and external factors in and before the adoption and implementation of an innovation like RFID. Acknowledgement The authors wish to acknowledge the support from Mr. Nick Chow and Miss Alice Tsang of ESI, the dealer of Alien Technology Corporation in Hong Kong.

8. References [1] Lee P . M. 2004. IT-Enhanced Service Quality in the Healthcare Industry.

International Journal of The Computer, the Internet and Management, Vol.12 No.3 pp. 96-103

[2] The Lewin Group, Inc. 2005. Health information technology leadership panel final

report. [3] Brailer D., Thompson T. 2004. Health IT Strategic Framework. Washington, DC:

Dept. of Health and Human Services. [4] Institute of Medicine. 1997. The computer-base electronic medical records: An

technology for health care. Washington, DC: National Academy Press. [5] Detmer D. E. 2000. Information technology for quality health care: A summary of

United Kingdom and United States experiences. Quality in Health Care 2000; 9:181-189.

[6] Mynatt, E.D., Rowan, J., Jacobs, A., and Craighill, S. 2001. Digital family portraits:

Supporting peace of mind for extended family members. Proceedings of the SIGCHI conference on Human factors in computing systems. pp.333-340.

[7] Mann, W. and Helal, S. 2002. Smart phones for the elders: Boosting the

intelligence of smart homes. Proceedings of AAAI workshop on automation as care giver: The role of intelligent technology in elder care, Edmonton Canada.

[8] Pollack, M.E., Engberg, S., Matthews, J.T., Thrun, S., Brown, L., Colbry, D., Orosz,

C., Peintner, B., Ramakrishnan, S., Dunbar-Jacob, J., McCarthy, C., Montemerlo, M., Pineau, J., and Roy, N. 2002. Peal: A mobile robotic assistant for the elderly. AAAI workshop on automation as eldercare.

[9] Correa F. A., Jos M., Gil J. A., and Red B. 2005. Benefits of connecting RFID and

lean principles in health care. Working paper05-44, Business Economics Series 10, July 2005.

[10] Kotler, P. 1994. Marketing Management- Analysis, Planning, Implementation and

Control. Prentice-Hall International, Inc., New Jersey. [11] Rogers, E. M. 1995. Diffusion of Innovations, 4th edition. The Free Press, ISBN: 0-

02-926671 [12] Herbig, P. A. and Day, R. L. 1992. Customer acceptance: The key to successful

introductions of Innovations. Journal of Marketing Intelligence and Planning, Vol. 10, Issue 1.

[13] Korunka, C., and Carayon, P. 1999. Continuous implementations of information technology: The development of an interview guide and a cross-national comparison of Austrian and American organizations. The International Journal of Human Factors in Manufacturing, 9(2), pp.165-183.

[14] Korunka, C., Weiss, A., and Karetta, B. 1993. Effects of new technologies with

special regard for the implementation process per se. Journal of Organizational Behavior, 14(4), pp.331-348.

[15] Pirkl, J., and Pulos, A. 1997. Transgenerational design: Products for an aging

population, NY: James Wiley & Sons. [16] Lin, L., Vicente, K. J., and Doyle, D. J. 2001. Patient safety, potential adverse drug

events, and medical device design: A human factors engineering approach. Journal of Biomedical Informatics, 34(4), pp.274-284.