The TechNation roundtable series continues this month with a look at asset tracking and real-time location systems (RTLS). Participants sharing their RTLS insights are ZulaFly Managing Partner Stephanie Andersen, Cox Prosight Product Director Jaiganesh Balasubramanian, Sonitor Technologies Inc. Chief Commercial Officer Matt Crane, Cognosos Director of Product Management Paula Dycaico, Medigate by Claroty Industry Principal-Healthcare Ty Greenhalgh, Capital i LLC Chief Operating Officer Shon McManus and Vizzia Technologies Chief Commercial Officer Dave Wiedman.
Q: What are the advantages and disadvantages of the different types of RTLS technology?
Andersen: There are a number of new RTLS technologies in the market today that are providing customers with cost-effective, easy-to-deploy systems along with very good location accuracy, that they may not have seen in the past. Since integrations with external solutions (EMR, CMMS, Nurse Call) is a niche for ZulaFly, the value add we bring is that not only are we hardware agnostic, but we have integrated our solution with a number of RTLS technology vendors in the market today. ZulaFly also has the ability to consume data from multiple hardware technologies deployed in a facility, to a single user interface; thus eliminating the need for “rip and replace.”
Balasubramanian: RTLS technology is a vital part of any hospital’s infrastructure. Effective RTLS will help your hospital in its journey to become a leader in the health care industry. As such, it is important for providers to consider which RTLS option is correct for their needs.
Wi-Fi-based RTLS technology utilizes pre-existing wireless access points to track assets. The primary benefit of a Wi-Fi-based system is that it uses a hospital’s pre-established infrastructure, eliminating the need for additional infrastructure costs. Wi-Fi-based RTLS tags consume more power, resulting in a shorter battery life on tags or frequent recharging and increased maintenance costs.
These systems also depend on existing access points for location computations and have lower accuracy compared to other systems (zonal/floor or unit level accuracy). Wi-Fi based RTLS systems may be unable to meet clinical requirements of hospital staff needing to know if an asset is in a room or not.
Infrared, or IR, RTLS technology is powered by technology that is like a television remote. A major benefit of IR is that it can be significantly more accurate than other RTLS technologies. Infrared sensors can track an asset’s location within 2 meters, outclassing several similar systems. High installation costs pose a massive downside to IR technology. Because the infrastructure is often powered by batteries, IR RTLS technology can be expensive to maintain. Battery power may also hinder this technology’s usability. Due to the technology being slightly outdated, IR tends to drain battery life at a rate unmatched by other RTLS technologies. Device accuracy may also be obstructed due to a tags’ line of sight being interrupted.
Ultra-wideband is a radio-based form of RTLS technology that aims to provide short and stable tracking technology. The leading benefit of UWB RTLS technology, by far, is location precision. This system provides an impressive accuracy of asset tracking within 30 centimeters. UWB achieves this using small, low-power tags using various software-based algorithms. The accuracy that UWB RTLS provides comes at a high cost — it is currently the most expensive of all RTLS technologies. A leading driver of this high cost is technology maintenance — requiring a robust network infrastructure as well as constant calibration to maintain accuracy. In addition to these drawbacks, UWB RTLS also results in a low battery life due to high power requirements, leading to additional maintenance time and costs. UWB-based systems also require robust data backhaul requiring a dense PoE (power over Ethernet) network to each receiver throughout the hospital increasing the cost and complexity of installation.
Ultrasound identification is a RTLS technology that utilizes simple, inexpensive badges and tags to transmit and communicate locations using microphones. On average, ultrasound can track assets within 3-5 meters. Although not as expensive as UWB, ultrasound RTLS is relatively expensive to install and maintain due to density requirements. Similarly, ultrasound RTLS may experience limited battery life. The line of sight of ultrasound RTLS can also be limited where tags are covered, resulting in limited application in more crowded hospitals and generally reduced accuracy
Bluetooth technology is common across all sorts of devices. In 2010, Bluetooth Low Energy — better known as BLE — was introduced with the release of Bluetooth 4.0, offering a form of Bluetooth technology that used much, much less energy. On top of ease of use, it’s far and away the most diverse form of RTLS technology. BLE provides asset tracking advantages like geofencing, zonal coverage, choke point coverage and maintenance management — among a variety of others.
The battery life of BLE is also the best on the market, with batteries lasting 5-plus years. Compared to other forms of RTLS technology — some of which can only give you up to 90 days of battery life — BLE greatly outclasses the competition.
In addition to its diversity of use and stellar battery performance, BLE is also very accurate. BLE can track assets within 3-5 meters, which is comparable to almost all other forms of RTLS technology. When compared to IR or US based systems, BLE RTLS technology has lower accuracy. However, it still meets room-level accuracy standards, meaning this weakness is negligible within hospital settings.
Crane: Health care facilities can be some of the most complex environments. Choosing the right RTLS that future proofs a health care facility’s investment by allowing them to seamlessly expand from the simplest of use cases, such as asset tracking that may only require zone level accuracy, to the most demanding use cases, such as staff safety and workflow that require bed- and or bay-level accuracy, is an important and critical decision. RTLS solutions based on Wi-Fi and BLE are primarily communication tools, not positioning tools. Signals from these technologies are inherently designed to efficiently travel through walls, glass and floors, and as a result can deliver predominantly zone level accuracy. This might be sufficient if a facility is solely interested in tracking or locating assets and not doing more advanced RTLS use cases such as asset utilization, inventory management, PAR level management, staff safety, rounding, nurse call automation, etc. But as we all know, health care facilities are looking to get the highest return on investment (ROI) from their RTLS. The best way to do this is by choosing the right initial infrastructure from the beginning so that they can layer on additional use cases that can deliver incremental value. Most, if not all, of these use cases require a higher level of accuracy (room, bay, bed, etc). For these more advanced use cases, true positioning technologies are required. Ultrasound-based technology has proven, in side-by-side comparisons, to deliver the most accurate and reliable positioning data down to room-, bay- and bed-level, while also requiring the fewest number of devices. Ultrasound signals are reliably and consistently contained within walls, glass and floors and will not “hop” or “bounce” out of its location, unlike infrared (IR) and ultrawide band (UWB). These other technologies require significantly more devices to block and contain signals to try to mimic the accuracy ultrasound can deliver with a single device. In addition, unlike IR, ultrasound does not require line of sight. This is acutely important in staff safety deployments. Think of this in the same way a remote control for a television functions. If someone is standing between the remote and the IR sensor on the TV, the channel will not change. If someone is standing between a caregiver pressing a button on their tag and someone is standing between them and the IR sensor, the duress signal from the tag will not get through. Most health care facilities do not want to do just asset locating and tracking. In summary, by choosing the wrong RTLS up front for a single use case, health care facilities may limit the value they get out of their initial investment.
Dycaico: In its simplest form, the differences in RTLS technology are as follows: there are highly accurate and expensive solutions, and ones that are more affordable but not accurate enough to measure any real efficiency improvements. The most significant similarity (and possibly only) between these two types of RTLS technology is that they both make it very difficult to produce a hard-dollar ROI. Luckily, advancements in cloud, AI and machine learning have drastically helped reduce the accuracy versus affordability tradeoff, enabling the next generation of RTLS technology to provide a highly accurate and ultra-lightweight solution, including a measurable, hard-dollar ROI.
Greenhalgh: Health care leaders invest in RTLS to gather data to forecast equipment requirements, identify trends in utilization, and optimize staff efficiency and patient safety. The Bluetooth Low Energy (BLE) and Wi-Fi technologies, which use Radio Frequency Identification (RFID) are not “Star Trek” level accuracy sometimes leaving “circles of uncertainty.” However, RTLS can integrate with a medical device security platform (MDSP), like Medigate, to correlate network device location details with the RTLS data increasing the location accuracy within HDOs.
McManus: RTLS technology has witnessed significant growth the past 10 years as it penetrates the manufacturing, health care, transportation and government markets just to name a few. With growth comes opportunities for innovation, which drives competition; as such, consumers now have a variety of RTLS technologies to choose. Most people are familiar with the Active and Passive Radio Frequency Identification (RFID) typically used in supply chain logistics and container tracking. RFID is a proven technology with global standards and a relatively strong signal with long read range capability. Some of the drawbacks are the size of the tags, especially with Active RFID due to the energy supply, and the physics behind RF – this can create interference when not considered. Ultra-Wideband (UWB) is becoming more popular due to the exceptionally low power level coupled with the high transmission frequency. This technology is minimally impacted by metallic surfaces and can precisely track thousands of tags within a facility.
Wiedman: Manufacturers are continuously developing new wireless technologies for multiple industries. Health care facilities represent a unique challenge, given the different infrastructure materials and clinical uses cases that are specific to each hospital. Vizzia operates an IOT Lab at the University of New Mexico. The lab serves as an objective testing ground to evaluate emerging sensor technologies (i.e., Bluetooth, Infrared, RFID, Ultrasound, Ultra-Wideband and Wi-Fi). As Vizzia is hardware agnostic, we can recommend which solution will work best in a specific health care facility.
Q: What are some of the newest features available?
Andersen: It’s important to find a system that allows the customer to create the fields with information they would like to see and gather data for. The ability for each facility to customize the information displayed within the dashboards not only creates shorter ramp up time for staff, but also allows for a seamless integration to CMMS systems. The ideal solution will also provide options for multi-asset search and the ability to view those assets on maps. You will also want a solution that provides a mobile app for users on the go. Reports on asset usage for reimbursement purposes should also be available as part of the standard solution.
Balasubramanian: RTLS 2.0 as it’s been termed offers significant advantages and improvements over legacy RTLS solutions. RTLS 2.0 allows hospitals to deploy a platform solution and unlock several uses cases including asset tracking, staff duress and workflow, environmental monitoring, patient wandering/elopement/workflow without the need to constantly add more infrastructure. The newest features include the ability to integrate with other health IT systems like asset management or EMR/EHR without significant cost of hurdles eliminating the silos which exist in these systems today.
Crane: Post-pandemic, there is a growing interest in three types of applications for RTLS: hand hygiene monitoring; contact tracing; and infection control. The common theme among these emerging applications is to enable the health care enterprise to improve patient and staff safety while providing data to operational leaders that support process improvement regarding workflows in and around direct care areas.
Sonitor has developed and introduced SenseClean Hand Hygiene Modules, devices that seamlessly integrate with the leading soap and gel dispenser manufacturer on the market.
SenseClean Hand Hygiene Module-enabled dispensers support hand hygiene best practices as defined by Leapfrog and compliments direct observation processes at health care facilities. Direct observation is valuable to promote training best practices, but to truly capture, monitor and improve compliance while reducing the administrative burden of data entry and post-reporting analytics, SenseClean Hand Hygiene Module enabled dispensers, when coupled with a Sonitor Sense enterprise deployment where staff are wearing Sonitor RTLS badges, automatically captures the dispense event (associated with the specific dispenser), the number of dispenses from a specific dispenser, and the battery life time status of the dispenser. This data, along with the association of which badged staff member triggered the event, allows facilities to monitor compliance accurately and reliably in a fully automated way.
Dycaico: One of the newest and most impactful RTLS features is the enhanced real-time visibility of clean and soiled rooms. Now, RTLS solutions can self-report inventory levels. For example, if inventory falls below a set threshold, the RTLS system will automatically alert teams and provide room specific picklists to ensure PAR levels are always maintained. Another notable feature is the ability to not only alert staff of equipment loss in real-time, when the asset passes by an exit monitor, but also provide support for them by allowing them to use the mobile app to use “nearby” to locate the asset. For example, a wound vac passes by an exit monitor that leads to a soiled linen area. The exit monitor will send an alert by SMS message or email to a staff member. The staff member can go to the area and use the nearby function to locate the asset.
Greenhalgh: RTLS technology continues to evolve providing environmental services (EVS) for patient room and bathroom cleaning, automated reminders for cleaning, repair, and preventative maintenance. Prioritizing tasks and notifications if temperatures drop in refrigerators or a door is left open is an example of how some hospitals used the technology during COVID to protect vaccines.
McManus: Some newer features integrate other facilities functions with RTLS. Some of these functions include integrating with the building management systems, like lighting and HVAC systems. Newest features also include tags with accelerometers that can save on battery life and provide additional information when devices are moved.
Wiedman: Advanced data analytics and actionable reports have become table stakes for RTLS software. Biomeds, clinicians and the C-suite want a robust software solution that provides comprehensive visibility into a hospital’s assets.
Q: How can asset tracking systems help a health care facility save money?
Andersen: There are a number of ways that an asset tracking system can provide a hard dollar ROI: asset utilization; PAR level on supply closets; notifications on rental equipment when equipment is no longer in use; staff time saved when needing equipment; and most importantly is understanding your facility spend prior to deploying an asset tracking system. This will become your benchmark to compare against moving forward. Utilizing historical asset location reports also assist with reimbursement of equipment usage that was used for specific procedures.
Balasubramanian: Asset tracking systems can help reduce search time for equipment for nursing, clinical engineering and biomedical teams. Improvements translate into the various teams’ focus more on care, equipment maintenance and replenishment. Asset tracking can help improve utilization of equipment, hence reducing yearly repurchasing of equipment not needed and reduction in rental costs. In addition, it can help reduce loss of equipment by alerting when equipment leaves a building or has been left unattended. Asset tracking can help improve and automate various asset workflows including preventive maintenance, rental returns and replenishment.
Crane: Studies conducted by Gartner and AMR Research found that, on average, hospitals lose, can’t find or have stolen 20-30% of their mobile medical equipment (IV pumps, bladder scanners, wheelchairs, etc.) annually.
An average inpatient hospital has 8-13 such assets per bed and the average asset cost is $5,000. If we take an average of 5 assets per bed, a 200-bed hospital will have approximately $5,000,000 invested in clinical mobile asset inventory.
With RTLS, a hospital can reduce lost and stolen assets, minimize the need for surplus inventory and eliminate the need for duplicate rental inventory by an average of 20%.
For a 200-bed hospital, this could result in over $500,000 annually in savings (Reference: https://www.sonitor.com/solution-briefs).
Dycaico: RTLS gives teams a clear and comprehensive view of the utilization of any class of equipment, enabling evidence-based procurement decisions that lead to meaningful savings. Essentially, the data collected from RTLS helps staff determine whether a purchase is required, saving hospitals and health care facilities from unnecessarily renting equipment or purchasing assets. Moreover, exit monitors reduce the costs associated with loss and theft, while enterprise-wide insights save money by enhancing general processes and efficiencies.
Greenhalgh: Many institutions suggest upwards of 50% of a technician’s time is spent searching for devices. This variable alone can often provide an adequate ROI for investing in an RTLS. Avoid unnecessary device purchases to replace mistakenly “lost” or “missing” devices. Combining MDSP data with RTLS data, users can support day-to-day operational workflows, such as preventative maintenance and recalls, by identifying the network location of the devices and pinpoint them on a map further supporting the business case for RTLS.
McManus: The return on investment or cost savings associated with asset tracking systems inside a health care facility will be realized immediately, especially for the larger facilities with tens of thousands of medical devices. First, accountability of the medical device – administrators no longer must worry about equipment being shoved into storage closets never to be found again … but needing to spend money to replace. Second, RTLS improves efficiency of service and maintenance of the medical device. Technicians will not spend countless hours (money) in search of the device; this will increase productivity and decrease downtime. Most importantly, mitigation of risk, which is ever prevalent when a “missing” life-saving medical device that could not be serviced finds its way onto a patient. The liability costs associated with an event like this could be unimaginable.
Wiedman: The benefits enjoyed by biomedical and supply chain leaders include: increased equipment utilization to 75%; reduced equipment CAPEX; decreased rental fleet size; reduction in device shrinkage; and reduced PM and search time. I led a RTLS educational session at AAMI eXchange 2022, which profiled case studies of $10 million in savings from 8 prominent health care systems (Wake Forest Baptist; Adventist Health; Texas Health; CHRISTUS Health; Oregon Medical; Emory Healthcare; Providence Mission; and Piedmont Healthcare).
Q: Is cybersecurity a concern when it comes to asset tracking technologies?
Andersen: Security is a concern that should be taken very seriously when deploying any technology within a health care facility, ensuring solutions are HIPAA and SOC2 compliant. ZulaFly takes cybersecurity seriously regardless of the application, whether it’s asset management, staff safety or patient workflow, that we are implementing for our customers.
Balasubramanian: Cybersecurity should be an important consideration when selecting asset tracking solutions. Some elements to consider include HIPAA, NIST and SOC 2 compliance. This ensures that the solution being considered adheres to the most stringent requirements in health care for security, data protection, encryption and identity/access management.
Crane: When thinking about cybersecurity, it’s all about identifying the weakest link within your system and, unfortunately, no system is completely immune. Sonitor does not store any critical patient or hospital sensitive data as we only capture and transfer location data to our partner’s application software.
However, with regards to asset tracking, understanding the impact a breach might have can help you develop the appropriate safeguards. For example, if the location data of an asset is changed as a result of a breach, what impact would that have on hospital processes or workflows? If the assignment of an asset is changed, what effect would that have? At worst, this might disrupt flow and cause some inefficiencies.
Dycaico: When considering RTLS technology, hospitals should look for a system that functions independently of Wi-Fi and other technology platforms that house PHI or protected information. Doing so will ensure that wireless networks don’t experience interference or unnecessarily heavy traffic and will eliminate potential access points for a cybersecurity incident.
Greenhalgh: Visibility is the cornerstone to any cybersecurity program. You can’t protect what you can’t see. Device identification includes knowing the make, model, serial number, MAC, IP address, OS version and the physical location of the device. Prioritizing risk and mitigation response times are often based on where a device is located, the ER versus an outpatient clinic. The same device with the same vulnerability but in different locations often have different risk levels and severity of impact. Knowing where every device that creates, stores, transmits, or receives ePHI is a HIPAA security rule risk analysis requirement. The combination of an RTLS with an MDSP system can more accurately alert security operations when devices containing ePHI are lost or “walk out the door.”
McManus: With any broadcasting or transmission technology there are always cybersecurity risks associated with use. Consumers must mitigate these risks by clearly defining their requirements, assessing the technology that best meets their needs, and implementing all safeguards during installation of the RTLS. Consumers should not let the cybersecurity risk detract from the overwhelming benefits of an RTLS – understand the risk, mitigate the risk.
Wiedman: The Vizzia enterprise platform has been built from the ground up, specific to the unique needs of the health care industry. We are intentional in deploying advanced technologies and best practices that address both infrastructure security and compliance regulations. Amazon Web Services (AWS) is our data hosting partner, which meets both HIPAA and HITRUST standards. We are also undergoing System and Organization Controls (SOC–2) compliance, as established by the American Institute of Certified Public Accountants (AICPA).
Q: What are some best practices when it comes to integrating RTLS into a health care facility?
Andersen: Start with the “must- have” functionality first, such as simply providing staff the ability to quickly locate equipment. From there, it’s easy to add-on PAR level, asset utilization, rental equipment dashboards, preventative maintenance dates, and so much more that can quickly provide a hard and soft dollar ROI. Since RTLS provides many use cases and applications, make sure to include multiple departments in RTLS conversations; security, biomed, supply chain, pharmacy and nursing to name a few. Buy-in from leadership will prove vital in a successful RTLS deployment.
Balasubramanian: Some of the best practices when integrating RTLS into a health care facility include
- Formalize departmental ownership and collaboration, ensuring buy-in and role definition among IT, clinical experts and nurses.
- Plan use cases early and have a clear understanding of how they’ll improve outcomes. This includes planning how to integrate the RTLS solution with existing workflows and other software solutions to achieve improved efficiency, cost savings and other outcomes.
- Set up use and maintenance processes for RTLS, such as battery replacement, as well as badge and tag ordering and general equipment upkeep.
- Make smart use of vendors’ expertise. RTLS companies have the insights that can help organizations chart strategy or set up effective integration with other systems.
- Channel RTLS data into continuous process improvement and workflow efficiencies. More impactful outcomes require analyzing data, making changes and continuing to follow up on progress.
Crane: Include clinical staff from the beginning and throughout the process.
Ensure there is a well-defined plan and ownership over maintenance and management of the system, whether it’s done in house or outsourced. For example, who and how will batteries in tags and devices be monitored and changed?
Be transparent as to how reports and data will be used – make sure it focuses on value to caregiver/patient versus using information in a punitive way.
Make sure to map out and understand what data sources will feed what applications. Is it one data source to one or one to many?
Dycaico: First, it is best for health care facilities to understand and outline what they want from their RTLS. If that answer is simply to find equipment, then RTLS technologies like Wi-Fi or typical Bluetooth Low Energy (BLE) solutions may be the best fit. However, the true ROI of RTLS isn’t just in locating assets – it should be about supporting automation and producing actionable insights to assist with critical decision-making and workflow enhancements. Delivering high-confidence room-level (even in open spaces) location tracking Cognosos’ next-generation RTLS solution is the more comprehensive option, enabling improvements across operations.
Greenhalgh: Technicians having access to device locations can have tangential benefits for IT, who are often interrupted from their work to help find a wayward device. Work order management can also be positively impacted by an RTLS. The ability for clinicians to initiate a service request without interrupting their daily activities. Simply pushing a button can create a work order and pushing it again, when the BMET is finished with the service call, updates the work order as complete. The time savings for automating this process are potentially significant.
McManus: When integrating RTLS into a health care facility it is best to take a wholistic approach. This is Project Management 101, first you need to identify key stakeholders and get their buy-in. Next, outline the expected outcomes and goals you desire to achieve with the RTLS (some refer to this as KPI’s). This will be specific to each facility and leadership team. Then we get into the nitty gritty, identify number of devices, technology platforms and software that would require integration, degree of location accuracy required for the project, etc. All these steps should direct you to the RTLS system that best fits your facility’s needs.
Wiedman: Lessons learned from our 15-plus years of “go-live” experience with hospitals and clinics nationwide, have been published in a 15-page industry white paper. There are four key best-practices for HTM executives to utilize: 1) discover the top pain points in your hospital; 2) build a cross-functional steering committee; 3) select equipment and devices for tracking; and 4) identify KPIs to measure success up front.
Q: Is there anything else you would like to share with TechNation readers?
Andersen: I would suggest looking for a solution that is cloud hosted. Cloud-hosted solutions are much quicker to deploy, easier to support, require less IT resources and are typically more cost effective. Do your homework, understand the platform that the asset tracking system is a part of and if there are other applications you can add on at any time so that you continue to see the value of your investment. I would also add that deploying a system that has a platform designed and developed by RTLS experts will go a long way in integrating disparate systems, producing analytics from data collected for operational business decision making, providing real-time notifications and customizable dashboards for the end users.
Balasubramanian: There has been considerable technological evolution over the last few years with Bluetooth Low Energy (BLE) leading the way. BLE provides significant cost savings while providing improved battery life of tags and ease of deployment and maintenance. Investing in an extensible IoT platform should be considered compared to a purpose-built asset tracking solution. A platform will provide extensibility to other problems the facility wants to solve in the future including wayfinding, staff duress, environmental monitoring and patient flow solutions without a significant reinvestment. With caregivers and clinicians on the go, a solution that provides the staff the mobility and visibility in the palm of their hands would be important to realize broader benefits.
Crane: The next few years are going to be very exciting for RTLS. As hospitals continue to be resource challenged, it is important to look at technologies such as Sonitor Sense RTLS that are easier and quicker to deploy and maintain. RTLS should not be viewed as an “asset tracking tool” or a “staff safety tool.” RTLS is a platform that enables a wide variety of use cases and delivers operational efficiency and higher quality care across the health care continuum. It’s important for health care facilities to understand the full breadth of capabilities RTLS can deliver so that they can leverage the most out of their investment. Key things to consider when evaluating an RTLS include:
- Location accuracy
- Number of use cases supported with a single company and technology platform
- Ease of deployment
- Ease of maintenance
- Post-sales support and partnership
Dycaico: The next generation of RTLS is here to fulfill the unmet expectations of past generations. Unlike other RTLS solutions that only gave accurate location information but nothing close to actual ROI, Cognosos’ RTLS exceeds expectations and delivers vital insights and immediate cost-saving benefits. Health care organizations can finally use these invaluable insights to eliminate unnecessary equipment purchases and wasted capital that can be better used elsewhere within the facility.
Greenhalgh: The efforts of hard-working BMETs are integral to quality of care, clinical outcomes, risk management and the overall patient experience. It is common sense that BMETs should be given the solutions necessary to locate any medical device required in supporting these primary goals of value-based purchasing.
Wiedman: Given the variable components that comprise a robust RTLS solution, 2 key factors have resulted in successful outcomes. First, utilizing a fully managed and integrated solution that has one SLA for hardware, software and ongoing support (vs. multiple vendors). Second, selecting providers that can partner with you as your facilities expand and use cases evolve.
