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February 2008

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As healthcare organizations chase after "high-tech" to describe their capabilities, they have yet to shed "high touch" as part of their ongoing administrative, clinical, financial and surgical operations.

That may be good news for bar coding products in an industry captivated by radio-frequency identification (RFID) and real-time location systems (RTLS), which are regarded as next-generation tracking technologies.

But that doesn’t necessarily mean the end is near for bar coding, which some vendors see continuing to function as a preferred tracking technology or as a stepping stone to chip-based technology in the future.

Healthcare Purchasing News Senior Editor Rick Dana Barlow posed a series of questions to seven key players in the bar coding arena, focusing on whether multidimensional options will sustain the technology’s acceptance and usability in the future. Among the vendor executives offering insights are: Debbie Murphy, global practice leader, healthcare, Zebra Technologies Inc.; Mike Poldino, vice president of advanced data capture for the enterprise mobility business, Motorola Networks & Enterprise; Jeffrey Schou, director of healthcare solutions for the enterprise mobility business, Motorola Networks & Enterprise; Keith Lohkamp, product strategist, supply chain management, Lawson Software Inc.; Ken Woodruff, industry director of healthcare, Lexmark International Inc.; Ralph Moher, vice president of marketing at General Data Corp.; and Dave Stewart, healthcare team director, Hand Held Products.

LOHKAMP: Linear can be read very fast by a laser scanner.

MOHER: Traditional linear, single-dimension bar codes can be scanned with an inexpensive linear scanner and are much more prevalent throughout the industry than the multi-dimensional bar codes.

MURPHY: Linear, single-dimensional bar codes are more cost effective than 2-D or 3-D codes. Even though imagers for 2-D and 3-D symbologies are becoming less costly, they are not as cost effective as laser scanners. In addition, linear bar codes are the FDA standard for labeling medications, so facilities that opt for this method can easily take advantage of manufacturer-applied bar codes.

SCHOU: Traditional linear is the simplest to print and certainly the most intuitive to most people, as everyone has been scanned as they’ve checked out of the grocery or retail store. 3-D bar codes have not reached adoption levels where their effectiveness can really be judged, but in many cases they may hold more data than needed for a given application. Also, cost and form factors for equipment to read such codes are still a challenge. In patient identification, I’ve long made the case that as long as you have a wireless network, the only information you want to encode in the wristband is the patient identifier, typically the MRN. Any additional information besides that, i.e., allergy information, current medications, current medical conditions, etc., are subject to change, thus creating an avenue for error as this information can change. By identifying the patient and wirelessly accessing the patient’s data in your clinical systems, you’ve assured yourself you’re looking at the most recent available data.

LOHKAMP: [2-D] Provides additional information in a single scan, on a small label or surface area.

MOHER: Two-dimensional bar codes are excellent carriers of large amounts of data and have a built-in redundancy that allows bar codes to be scanned even if they are damaged.

WOODRUFF: 2-D bar codes can be easily printed on-demand at low cost, and many software solutions exist to integrate between HIS systems and output devices. 3-D (embossed bar codes) requires specialized devices to produce on-demand. Some 2-D bar codes, such as Aztec, are easier to scan than long 1-D bar codes on wristbands.

MURPHY: Two-dimensional bar codes are space-efficient and can encode a significant amount of data. In addition, Aztec Code is well suited for patient identification applications because it allows nurses to scan a wristband regardless of its position on the wrist. In addition, the costs of 2-D imagers are coming down, which are making 2-D codes a more attractive option.

POLDINO: 2-D has the significant advantage of being ‘omni-directional;’ namely, you don’t have to orient the scanner to a particular angle to read the bar code. That’s why you see 2-D codes being adopted more and more for patient wristbands. In the future, we may see more medications using 2-D codes to contain lot number and expiry information, in addition to the drug identification information. 3-D codes have yet to reach mass adoption and may actually have data carrying capabilities that exceed the need for most applications in the clinical setting.

LOHKAMP: [3-D] provides very rich content, but requires very specialized technology. Full benefits remain unproven.

MOHER: Three-dimensional bar codes are primarily used in injection molding of plastic parts and are not very relevant in healthcare.

WOODRUFF: 3-D (embossed) bar codes can be created on materials that can be used in extreme conditions, e.g., high heat or environmental conditions that could destroy paper/ink. For static bar codes, such as an asset number or product ID, the embossed bar code could be imbedded directly onto the item, eliminating the cost of separate labels.

MURPHY: Three-dimensional bar codes are read by using differences in height, rather than color contrast. This feature makes 3-D codes particularly useful for objects that are not easily labeled, such as curved surgical instruments made of metal.

LOHKAMP: As bar code technology improves, patient safety will improve based on medication verification and tracking of surgical instruments. As a result, the cost of care also will be lowered.

STEWART: Improvements in wireless communication between bar code portable data terminals with portable printers and smart monitors/pumps will continue to enhance patient care.

MOHER: At General Data, the next big development we see is a complete, integrated system that uses the bar-coded patient wristband to extend to all functional areas of the hospital. 

WOODRUFF: Print-on-demand forms with bar codes to encode patient demographics; form type and document serial number is becoming an important ‘EMR Readiness’ initiative. Preparing forms with on-demand bar coding automates scanning into EMR systems. Distributed scanning of time-sensitive bar-coded documents will also be used to improve the quality of patient care, e.g., scanning advance directives and updated consent forms after admission. Bar codes can be used to automatically file a document into a patient’s electronic medical record, and/or automatically route documents to speed up access to critical information.

MURPHY: Innovations in adhesives, label materials and over-coatings will be introduced, helping to make materials stronger and more durable for the healthcare environment. Many of these innovations will also allow bar coding applications to serve double duty. For example, Zebra’s new patent-pending antimicrobial wristband coating not only offers hospitals an effective solution for positive patient identification, but it also protects wristbands from bacteria that cause infection. As bar code technology advances, it will continue to offer new enhancements like this that allow providers to accomplish several objectives with one product.

SCHOU: Within healthcare, I think you’ll see more medical devices embed bar code technology to take advantage of things like positive patient identification and linking patient data taken from a medical device to the patient’s electronic health record. Imagine a cardiac unit where they bring in a heart monitor, scan your wristband, and instantly all the data being displayed by the heart monitor is also being sent across the hospital’s network to your electronic health record where it’s saved for review later today or where it can be compared to your EKG ten years from now. That’s where I think you’ll see the technology popping up next. We’re already seeing infusion pumps taking advantage of the technology to automate the programming of the pump. 

LOHKAMP: Improving the speed of 2-D and 3-D bar code readers.

STEWART: Better utilization of 2-D symbologies. The ability to encode more data is not utilized. For example, the secondary data on pharmaceuticals, which includes the lot batch, expiration date.

MOHER: If there is one thing that we would change that would spur adoption of bar coding in the healthcare industry, it would be education of the users about the benefits and cost savings gained using the technology. Healthcare is still 20 years behind other industries.

WOODRUFF: Improvements are needed to simplify and reduce the cost of implementing bar codes – Lexmark is focused on providing end-to-end solutions that take care of the work of integrating with the HIS system, assuring high-quality bar code output for reliable scanning, and integrated features in standard laser printers to produce bar code to eliminate the need for specialty devices. Improvements are needed to make using bar code technology easier for end-users – for example, Lexmark has introduced a simple touch screen user interface on their [multi-function products], similar to a GPS screen in a car, that enables clinicians to access forms for on-demand printing with bar codes without the need to go through the extra steps of logging into a PC workstation.

MURPHY: I would change the perception of bar coding in the marketplace. With all of the hype surrounding RFID and RTLS, it’s far too easy for hospitals to view bar coding as ‘old technology’ rather than a ‘proven technology,’ thereby overlooking all of the capabilities it has to offer. If potential buyers had a better understanding of the technology and its advantages over RFID, adoption would increase significantly. The industry as a whole has barely scratched the surface on the potential of bar coding, especially considering its ability to transform processes for improved patient safety and greater efficiency.

SCHOU: My personal opinion is that the largest problem we have right now involves the proper printing of bar codes on medications and wristbands. Properly printed, this is a non-issue. Not properly printed, it leads to frustration on the part of nurses. If I could wave my magic wand, this would be the first thing I’d fix.

Fast forward to the year 2017 and project bar coding’s applications, functionality and pervasive use in healthcare facilities, in comparison to RFID and RTLS.

LOHKAMP: RFID and RTLS will likely be important technologies that support specific needs for location identification, tracking and other rule-based processes. In many cases, we can anticipate that IT technologies will combine RFID, RTLS and bar codes to deliver a solution that is flexible enough to handle multiple business scenarios. Specifically, bar codes may still play an important role in business processes that require human interaction and a direct scan of a specific item or asset.

STEWART: Bar code scanning will be a natural process in the daily lives of caregivers. RFID and RTLS will have comparable installations of bar coding today.  

MOHER: By 2017, problems with RFID will have (hopefully) been worked out, and bar coding, RFID, and RTLS will exist as complementary technologies working in a complete integrated system.

WOODRUFF: We will see a combination of bar code and RFID technology. Cost of print-on-demand RFID tags will drop, as well as the cost of devices to program, verify and scan them. However, bar codes will continue to be used in many applications where there is insufficient added-value to justify the incremental cost of RFID.

MURPHY: It is likely that all three technologies will work side-by-side for many years to come. There are applications that are better served by bar coding, and there are specific applications that are well served by RFID and RTLS. A combination of these technologies will allow hospitals to realize the most gains in terms of cost effectiveness, time savings, accuracy and patient safety.

SCHOU: I believe that RFID and RTLS will be prevalent in high acuity areas where the cost of automating certain processes is justified based on the cost of care in these areas. In the med/surg area, I think bar coding will be a highly integrated application that eliminates many manual steps taken today to link information from the many disparate clinical systems. I think a few scans will link patient records with outputs from many medical devices which in turn will make processes for the clinical staff more efficient and make the billing/financial process more accurate and auditable. In 2017, RTLS technology will have matured to the point where every hospital can pinpoint the location of every infusion pump, ventilator and wheel chair within their facility.