Healthcare organizations must read between the lines for ongoing progress

The monumental feat represented the culmination of a hard-fought effort to make bar coding the retail rule of the industry, roughly a year after retailers accepted Global Standard 1’s (now known as GS1’s) standard as the uniform method for identifying and tracking products.

Since that time, bar coding as an identification and tracking mechanism migrated to other industries — including healthcare, where the now-retired hospital supply chain executive Frank Kilzer made bar coding the cornerstone of his supply chain operations in North Dakota the year following its official debut in retail.

Back in the mid-1970s, the band of vertical stripes arrayed in such a way that it carried useful and valuable information for sales and supply chain, seemed remotely futuristic. These days, however, in the era of smartphones, tablet computers, real-time location systems, and chips and tags, those stripes seem downright quaint.

But developers have helped the stripes to innovate, too. During the last few decades, next-generation variations of bar coding formats have emerged, including two- and three-dimensional options that are designed to carry even more information in the Big Data era, as well as the latest wrinkle with color-coding.

In fact, as the traditional linear or 1-D bar code celebrates its 40^th anniversary this year, the 2-D bar code celebrates its 20^th.

So in this era of healthcare reform regulations, reimbursement and budget cuts as well as enterprise data demands, what could be worked into the format next to push it forward?

What could suppliers do with the spaces between the stripes? Could altering the angle or changing the direction of the stripes provide additional flexibility? With Generation X now entering middle age, how can this identification and tracking modality appeal to the Generation Y crowd and beyond? What if the bar code were printed using programmable electronic ink so that the data and information it carried could be more fluid than finite and static?

Healthcare Purchasing News asked a group of bar coding executives their impressions about bar coding’s practicality and progressive outlook based on its composition and past performance.

As the specter of advanced tracking and tracing technology looms larger, the applicability of bar coding — no matter the type — likely won’t diminish, sources told HPN. That’s because the ongoing utility of 1-D, 2-D, 3-D and now color bar coding among the variety of industries using them far outweighs their obsolescence.

Alexis Arenas

The differences between the various bar code symbologies are straightforward, according to Alexis Arenas, Strategic Accounts Manager, Barcoding Inc. "The more complex the code, the more information can be stored," she noted. "1-D is generally the simplest code and is widely used in inventory management, warehousing, and retail. 2-D codes are growing across industries and are widely featured in some of the largest [electronic health record] software, showing up as the small box code seen on a hospital wristband."

Arenas insisted that bar codes won’t be retired any time soon or even farther out. "While 2-D and 3-D bar codes are clearly the way of the future, there will always be a place for 1-D codes," she said. "1-D is the backbone of slim-margin industries like retailing and foodservice. 1-D codes are the easiest to use to organize a warehouse or distribution center. Hardware that works for these solutions tends to be the least expensive, while the standardization of services, inexpensive-to-maintain hardware, and easy-to-launch applications make this type of technology attractive to many industries."

In healthcare, bar codes must be used on packaging and devices to comply with the Food and Drug Administration’s (FDA’s) Unique Device Identification (UDI) standards being phased in during the next few years. "This is only one small facet of one vertical for bar coding — the applications for each type of bar code are endless," she added.

Ravi Panjwani

Ravi Panjwani, Vice President, Marketing and Product Management, Brother Mobile Solutions, indicated that Code 39, a 1-D linear format, has been "one of the most commonly used" since the inception of bar codes — particularly in healthcare for patient wristbands — "because it was easily supported by legacy hospital information systems." In fact, "it is still prevalent in hospitals, along with the high density Code 128, because of its compatibility with laser scanners and its comparatively lower cost. However, Code 39 bar codes tend to be long, making other more space-efficient symbology options preferable for wristband use," he said.

Healthcare organizations may be interested in 2-D bar codes because "they can store substantially more information in a much more compact space and can even serve as a portable medical record for the patient," Panjwani continued. He specifically cited the PDF417 symbology’s popularity among 2-D bar codes because it can be read with a simple linear scanner that offers more flexibility.

"Other 2-D options, such as Aztec, require a scanning device that includes an image sensor," he noted. "So clearly there are cost implications in moving from 1-D to 2-D. But 2-D bar-code features, such as large data capacity, error detection and correction are valuable in supporting patient safety initiatives."

Arnold Chazal

What primarily differentiates the 1-D/linear bar codes from other types of bar-code formats are the amount of space taken on the label and the amount of information encoded, according to Arnold Chazal, CEO, VUEMED.

"Linear barcodes are sufficient for most clinical products packages, with the exception of some packages where space is extremely limited and the amount of information that needs to be encoded is significant," Chazal told HPN. "There are relatively few types of clinical products on the market today that have such space constraints on their labels that they require a 2-D bar code. Sutures are a good example, as well as some small surgical instruments. The information encoded in 2-D bar codes on these products is typically the same as in linear bar codes: item identification/reference, lot and/or serial number and expiration date."

Andy Tippet

Andy Tippet, Senior Marketing Manager, Healthcare, Zebra Technologies, categorized 1-D/linear bar codes having the traditional stripes, but that 2-D bar codes consist of rectangles, dots, hexagons and other geometric patterns in two dimensions. Further, Aztec and color represent types of 2-D bar codes beyond the standard 2-D formats. "Aztecs have the potential to use less space than other matrix bar codes because it does not require a surrounding blank ‘quiet zone,’" he noted. "Color-coded bar codes or high-capacity color bar codes are also 2-D and provide the potential for color."

While 1-D bar codes contain "lower information density and depend on a database or communications network for interactivity," 2-D bar codes can contain "high information density, including voice, photos and need not depend on a database," he added.

Scott Clifford

Scott Clifford, Clinical Solutions Manager, Microscan, highlighted some of the useful capabilities and ongoing challenges of each type.

For example, 1-D/linear bar codes must be printed on high-contrast labels where characters are encoded as bar widths and spaces and decoded via an analog signal. In addition, 1-D bar codes carry a little amount of data and allow for very limited to no error-checking, he advised.

Meanwhile, 2-D symbols solve a portion of 1-D bar coding’s challenges because more characters can be encoded on 2-D symbols, offering greater data density, and they are decoded via a digital signal, he continued. "Characters are encoded based on the presence or absence of symbol elements, also called cells," Clifford noted. "Therefore, 2-D symbols can be decoded even if they are printed in low contrast or directly on parts (DPM).

2-D symbols offer more error correction capabilities, because "symbol data can be reconstructed even if 20 percent of the symbol is damaged or missing," he added.

David Kane

Because 2-D and 3-D bar codes involve a grid format, compared to 1-D/linear codes oriented in an array of parallel bars of varying width, they can "handle significantly larger amounts of information with minimal impact on the dimensions of the symbol," said David Kane, Product Manager, TEKLYNX. "Linear bar codes would have to grow quickly in size as information is added."

Consequently, available real estate — the amount of space on the product and its packaging — influence the decision on which bar code symbology to use, Kane added. In effect, label space is the "primary driving force" because "you can fit significantly more information in a much smaller amount of space when using 2-D [or] 3-D bar codes."

Paul Czerwinski, Director of Healthcare for North America, Motorola Solutions, linked bar coding’s progress to the advancements in scanning technology, including hand-held laser scanners, since the early 1980s. "Over the years [laser scanners] became smaller, better, faster and less expensive," he noted. "They are fantastic at scanning traditional 1-D bar codes printed on packaging or label stock. Linear imagers can now do everything laser scanners can, but offer the additional functionality of scanning ‘virtual’ 1-D bar codes or bar codes that are not printed but instead exist only as pixels on a computer or cell phone display."

Paul Czerwinski

More expensive array or camera-like imagers can scan just about any bar code format, including virtual, because when the user pulls the trigger, the scanner takes a picture of an area and then decodes the bar code from the digital image, Czerwinski said.

"Array imagers also are capable of advanced functionality such as capturing digital images and scanning optical character recognition (OCR)," he continued. "Another benefit of array imagers is omni-directional scanning, which allows the user to scan and decode a bar code from any angle without the need to orient the scanner, making array imagers inherently more productive than linear readers. With advancements in complementary metal–oxide–semiconductor (CMOS) arrays and microprocessors, latency has been eliminated, and array imagers are now as fast to decode as linear scanners."

Reviews are mixed about 3-D and color bar-code applications in healthcare, even as the latter only may be "breaking the surface," Arenas observed.

"3-D tends to be used in harsher environments, so we have not seen it adopted in healthcare," Panjwani said. "Nor do we see color bar coding, which many laser scanners cannot read. However, we are seeing different color wristband clips strategically used to define patient risks and clinician alerts."

Arenas indicated that color bar codes generally have gained prominence in television, video games and other media and are scanned by personal mobile devices, but warrant further exploration and investigation in other industries, such as healthcare, where scanners used in traditional automatic identification and data capture (AIDC) applications may need to change.

Clifford added that 3-D and color codes can be "more difficult to print and decode because color cameras are required."

When deciding which bar-code symbology to invest in and deploy, the simplest solution typically can be the right one, Arenas urged. But something that is relatively inexpensive and easy to implement also must be future-proofed with hardware and software options down the road.

"The safest path right now is to use digital imagers, as the ability to scan all types of bar codes eliminates the fear of having the wrong tool," she advised. "If there is a specific need to read DPM codes, DPM-capable imagers can be procured for just that use."

Cheryl Flury

Speed-to-implementation to leverage data should motivate and drive these decisions, emphasized Cheryl Flury, Vice President, Marketing, Jump Technologies.

"Getting started quickly may be more important than considerations about which type of technology to use," Flury advised. "There’s a large number of inexpensive mobile devices including smartphones and tablets, along with key-fob sized scanners, which can be given to a large number of team members while keeping costs low. With scanning apps for all types of devices and all types of bar codes, wide-spread deployment is quick and easy. Beginning to capture this data can provide the hospital with richer information about, for example, supplies being used across the organization, which in turn could begin the process of building greater understanding of cost, quality and outcomes."

Flury cited the hectic nature and rapid pace of the emergency department (ED) where clinicians must concentrate on caring for patients more than finding, recording and managing products they need to carry out their mission.

For example, in the ED of a large hospital in Pennsylvania, nurses expressed dissatisfaction with the high costs of the automated dispensing cabinet system they were using so they switched to a "grab-and-go" system for high-velocity products. Flury said, "Managing inventory using a two-bin system and scanning at a bin level rather than an ‘each’ level resulted in a climb in nursing satisfaction (to 90 percent from 15 percent), as well as a reduction of stock-outs and significant savings in cabinet leasing fees and inventory costs."

Still, any technology deployed must match the needs of the facility, she continued. "A simple, 1-D or 2-D bar code may contain everything that’s needed to track and manage supplies, and understand the velocity of inventory leading to cost improvement," Flury added. "For clinicians, making the use of technology as simple and efficient as possible is key. In a high-stress environment, and with nursing salaries representing the highest portion of the hospital labor spend, alleviating staff time spent away from the patient and reducing time spent managing burdensome manual tasks will directly relate to nurse satisfaction, and potentially reduce errors and overtime."

Operating within the confines of cost-conscious accountable and value-based care, healthcare organizations must balance the substantial investment required for more advanced scanning equipment with the efficiency, accuracy and patient safety aims they seek, according to Panjwani.

"Even state-of-the-art technologies are ineffective if they aren’t used properly and regularly," he continued. "Simply having the technology available doesn’t promote patient safety. The key is to seamlessly integrate it into workflow, enabling clinicians to view it as a tool that helps them provide safer, more efficient, higher quality care.

"To truly turn the tide on patient safety, hospitals need to expand the adoption of bar coding technology — even if it’s the most basic 1-D — into all areas of the hospital, from the patient room to the lab to the pharmacy. That way, anytime providers perform an action on or for a patient, they can easily scan bar-code labels with accurate drug-, test- and patient-specific information and then generate a data record entered directly into the patient’s EHR."

Choosing the right technology to deploy depends on the facility’s customized workflow processes and systems, which includes operating software system compatibility, according to Tippet. "If they need to capture large volumes of information including images, sounds and other high-density data, then 2-D may be the answer," he added.

Healthcare facilities must determine whether the larger volume of information captured in a noticeably smaller amount of space provided by 2-D, 3-D and color-coded bar codes outweighs the higher cost of the imaging technology needed to read the data, according to Kane.

Healthcare organizations should not overcomplicate their choices and sweat about automated cabinet systems or radiofrequency technology, according to Chazal.

Against the backdrop of complying with FDA’s UDI rule, and using any of the supply data standards systems available, hospitals need to control their costs and manage their clinical inventory all the way to the point of care, he noted. "There is no need for additional data to manage products other than the product ID and pedigree, all of which can easily and reliably fit into the 1-D bar codes currently in use on most clinical products," he said.

"The prevalence and low cost of 1-D bar code readers, added to the fact that this technology is deeply embedded in many other healthcare IT systems (including MMIS, billing, clinical documentation, admission, scheduling, etc.) means that 1-D bar coding is perfectly appropriate and effective for managing clinical items, implants, blood products, and so on from the manufacturer’s facility all the way to the patient’s bedside," Chazal added.

Bar coding on the brink … of further growth?