Auto ID Tug-of-War:
Bar coding vs. RFID
Hospitals letting the chips fall
where they may
After bar coding will RFID earn its
stripes in the healthcare supply chain?

First of two parts
by Rick Dana Barlow

Symbol Technologies Inc.

Trying to pit linear or even two dimensional (2-D) bar coding against the wildly buzzworthy radiofrequency identification (RFID) chip is akin to recruiting the intellectually cunning Batman to spar with the incredibly powerful Superman.

One hero won’t necessarily defeat the other but team them up and they’re virtually unstoppable against the nefarious forces of evil. The analogy to automatic identification technologies is uncanny. Even with the hype blazing white hot over the "revolutionary" RFID tag in healthcare, no one is willing to go so far as to say it eventually will replace bar code labels. In fact, it’s probably not fair to compare any hypothetical bar code-to-RFID evolutionary transition to CDs and MP3 files supplanting audio cassettes, which replaced eight-track tapes.

That’s because in some cases and for some applications bar coding may suffice as the optimal tracking solution where RFID would be overkill and needlessly costly. Hence, technological migration probably will be tempered somewhat, despite all the market reports that claim RFID will turn out to be the gold mine or brass ring that the Internet has yet to deliver.

"RFID and bar coding are not competitive technologies," said Don Flynn, vice president, business development, Hand Held Products, Skaneateles Falls, NY. "They’re highly complementary. A healthcare facility will say they want to use RFID and not bar codes. Well, why? We have to get away from this either/or mentality. What makes healthcare facilities think they can be successful with RFID when they haven’t fully adopted bar coding into their operations? It’s a mystery. I don’t know why."

Hand Held Products IMAGETEAM 5620

Frank Kilzer, vice president of material and facility resources at St. Alexius Medical Center (Bismarck, ND), and a pioneer in healthcare bar coding operations, recognizes RFID’s allure and value but doesn’t give the hype much credit. Both are machine-readable technologies that enable healthcare facilities to automate business processes, which will generate a financial savings, he noted. "RFID is not necessarily more popular [than bar coding] or without resistance," he said. "The attention RF is getting has more to do with bar codes having set the stage for how machine-readable technology can change business processes, and now people are aware that RFID can take this automation to another level." 

In 1985 Kilzer spearheaded the purchase of the first bar code technology system designed for healthcare. St. Alexius spent $50,000 to acquire the technology and two years trying to get it to work before discarding the system and replacing it with internally designed software to scan bar codes on all medications and supplies. In 1993, St. Alexius installed computers equipped with bar code scanners in every patient room to efficiently track supply and medication consumption at the patient bedside.

Debbie Murphy, global practice leader for life sciences, Zebra Technologies Corp., Vernon Hills, IL, doesn’t expect RFID to replace bar coding either. "I don’t see it happening," she said matter-of-factly. "Especially in healthcare where many facilities haven’t even adopted bar coding, which has been proven as a viable technology. We’re still seeing growth in the area of bar coding, which can be RFID-ready. At best the technologies are truly complementary."

"RFID has very quickly found its way to the hype cycle," Murphy said. "It’s enjoying tremendous buzz in every technology circle and industry because of its capabilities, primarily in supply chain applications. Most industries are looking to apply RFID there."

Symbol MC 9000-G

Wal-Mart represents a prime example. Beginning in January the leading retailer required its top 100 suppliers to affix RFID tags on pallets and cases. "They saw RFID as so important to their operations, in terms of supply chain efficiency, so they can manage inventory in real time and generate faster throughput," Murphy said.

In healthcare, however, that’s not necessarily the case.

Round robin
While the manufacturing and retail industries, by and large, have understood and been reaping the rewards of bar coding and RFID for decades in their supply chain operations, healthcare suppliers and providers remain relative newcomers to the concept. Some could argue that they’ve been conscientious objectors to an open-source system for various reasons, beginning with the failed Common Category Database project in the late 1980s to early 1990s.

Medical device and pharmaceutical manufacturers certainly recognized the benefits of auto ID technology for their own production purposes, implementing auto ID systems for internal use. But they hesitated to extend those capabilities fully to their provider customers because they worried that providers would be able to compare competitive products more easily (leading to commoditization and pricing parity) and would require the vendors to offer the technology for free. Meanwhile, many hospitals and other healthcare facilities hesitated to adopt and implement bar coding because they didn’t want to pay for it (financially and operationally), and there were no data standards in place for them to compare competitive products more easily.

"Resistance that resulted  from the perception that there was a lack of standards, or a single standard that everyone could agree on, had more to do with a lack of understanding on what could be accomplished with the standards that were available to us," Kilzer said. "It took the industry almost a decade to sort through this issue, even though scanner technology had the ability to auto-discriminate between the two standards. Unfortunately, concern 
over these issues was very costly at a time when energies could have been better spent understanding all that could be gained by implementing bar codes. 

"As for concerns about commoditization, the industry initially perceived bar codes and commoditization as one and the same initiative," he continued. "Time has proven that this was not the case. Commoditization occurred as a result of the databases that were developed for this purpose – not as a result of bar codes. I do not think that these concerns still exist but if they do RFID will not resolve them."

Not much has changed, however, even with RFID. "Hospitals will jump on it if manufacturers apply the RFID chips to their packaging, the same as bar codes," said Joseph Dysko, executive director, engineering and capital resource group, MedAssets Supply Chain Systems, Atlanta. "Hospitals want manufacturers to provide them with all the tools rather than program the chip and place it on the products when they come to the docks. The bottom line is that industry will do it because it has value to them. Hospitals will want to piggyback on those efforts."

Because it’s so new to the healthcare lexicon, RFID hasn’t developed the historical perspective enjoyed by bar coding fans and foes. RFID’s introduction, however, is receiving a much warmer reception in the hospital community than bar coding. Timing may be a key reason.

While the manufacturing and retail industries recognized the value bar coding and RFID brought to their supply chain, the healthcare industry gave bar coding more tepid acknowledgement by comparison. It wasn’t until healthcare began focusing on medical error prevention and patient safety at the turn of the millennium that bar coding started to really sizzle.

Similarly, RFID is generating significant interest and support for equipment tracking and patient safety, including tracking patient and staff locations, correct surgical sites and medication delivery. Ironically, where manufacturing and retail pursued auto ID techniques for supply chain effectiveness and efficiencies, healthcare has backed into it, focusing instead on auto ID adoption and implementation for largely non-supply chain functions.

Unlike other industries healthcare must contend with the clinical vs. financial and operational arguments for bar coding and RFID, according to Ken Kleinberg, global market leader for healthcare industry solutions, Symbol Technologies Inc., Holtsville, NY. The clinical perspective centers on bedside and surgical care with an emphasis on patient safety. The financial and operational perspectives focus on the storeroom and the supply chain with an emphasis on efficiency and speed, he observed.

"Hospitals have been notoriously behind the curve in cutting costs, improving supply chain efficiency and adopting new technology," Murphy said. "But with the pressure to improve patient safety by FDA, JCAHO and The Leapfrog Group, at least there’s a growing interest in bar coding.

"As hospitals look at patient safety issues and familiarize themselves with bedside medication monitoring the focus on inventory management will take root," she added. "Eventually, the market will demand this."

In fact, more hospitals are adopting bar code systems for patient wrist bands at the bedside and for medications, she noted. Even the FDA recognized that less than 10 percent of hospitals use bar coding so why force an otherwise unproven technology on a market that has a hard enough time with a simpler technology? she asked.

By the summer of 2006, however, all meds should sport a linear bar code at the FDA’s urging, and that label should include all the information a hospital pharmacy needs – lot and expiration date as part of the National Drug Code (NDC), Kleinberg said.

He also refuses to count bar codes out in favor of RFID. "It takes about 10 to 15 seconds to scan a bar code, so you’re talking about saving that much time when they have to read a drug bar code label anyway? Bar coding still has a lot of value. It’s a proven commodity, and many hospitals have demonstrated success with bar coding."

Balancing act
RFID offers certain benefits that bar coding cannot, but then bar coding provides certain benefits that RFID cannot at this point, sources told Healthcare Purchasing News.

"Bar coding has an advantage at the moment in terms of cost because the label itself is inexpensive, but that difference won’t be as great in the future," said Lydon Neumann, vice president, Capgemini’s health supply chain practice, Chicago.

"There are cost variances between the two technologies that must be considered, depending on what business practice is being automated," Kilzer said. "As a result of these differences it is unlikely that RFID tags will completely replace bar codes. From an operational standpoint bar codes have a proven track record for identifying medical and surgical products, medications, X-rays, equipment, medical records, patients, etc. It is better to implement bar codes today rather than wait until RFID has a similar track.   

"Comparatively speaking, bar codes are less costly to apply and the scanning technology is affordable," he continued. "The cost of a scanner is an important issue when considering the number of scanners that must be purchased to outfit every patient room." 

Flynn highlighted three distinctions between bar coding and RFID. First and foremost, RFID chips are read/write media whereas bar codes are read-only media. He admitted that not a lot of people are using the write capabilities of RFID yet. Second, RFID chips and interrogators do not require line-of-sight for successful reading; bar codes do. Third, depending on how the chips are packaged they generally are more durable than paper labels when exposed to harsh conditions, including fluid.

"But RFID still finds it very hard to beat the costs of ink on paper," he acknowledged, "even though the prices for RFID chips are starting to fall."

Dysko agreed. "A good quality laser printer can produce a readable bar code," he said. "But that’s not desirable."

The situation is even more pronounced on the equipment side where end users will pay a "very large premium" for RFID readers or interrogators, depending on the form and application.

In fact, the low-end price points for hand-held bar code readers are in the $300 to $400 range, he estimated. An RFID reader, on average, runs between $1,500 and $3,000. Compounding matters is that currently availability is a problem, he noted, particularly for equipment that reads the new Electronic Product Code (EPC) Generation 2 standards that use ultra-high frequency (UHF) to transmit data.

RFID chips and tags can include much more information on them than the less expensive linear or 2-D bar code. For example, a bar code may identify a patient’s name, location and doctor or identify the content and volume of a supply case, but an RFID tag can include patient data such as blood type, allergies and other vital statistics or in the area of supply packaging a track and trace feature (where the product is, where it came from and how it was made). The tags can carry information about all the contents of a surgical tray or a supply closet, accessible by hand-held scanners or door- or wall-mounted readers. Some high-end chips and tags are reusable and rewriteable.

RFID tags on equipment can carry data on where something is, where it was, when it was last cleaned and sterilized, when it was last repaired, when it was last used, by whom, for what, on whom?

Plus, RFID tags can be programmed to set off some kind of an alarm if a nurse mistakenly starts to administer the wrong medication or if a product is being exposed to problematic environmental conditions.

Another differentiator is that a bar-coded wrist band on an Alzheimer’s patient will identify that patient but an RFID wrist band can be programmed to close facility doors when that patient approaches to prevent him or her from leaving, according to Neumann.

"Doctors who have little or no role in bar coding will work with RFID because they can gain access to information about patients and their surgical sites right away," Neumann said.

In the simplest of terms, bar coding represents a license plate that refers to a database, Murphy explained. It carries static information that can’t be updated – a one-way stream of information. RFID, on the other hand, can represent a mini-database (depending on the chip) that can hold more information and be updated.

RFID enables omnidirectional reading and positive identification from the start without requiring full line-of-sight that bar coding needs. That reduces the likelihood of scanning errors and user training requirements. For example, even though printing a bar code on a patient’s wrist band can be done quite efficiently and cost effectively, according to Kilzer, the more costly RFID wrist band generally performs better. "The wrist band may not always be visible to the nurse at the time she needs to scan it," he said. "The patient could be sleeping, and the wrist band is under a blanket that will require waking the patient to scan the bar code." That’s why nurses will prefer RFID technology over the bar-coded band, he added. HPN