RTLS as Innovation

3.2.1 Relative Advantage Costs

RTLS has the potential for significant time and cost savings by tracking expensive or shared equipment, such as intensive care unit (ICU) ventilators or intravenous pumps, and reducing equipment theft and accidental loss (Malik, 2009, p. 36). Hospitals are typically large institutions, which makes it difficult for personnel to find portable equipment when it is required. Moreover, the practice of working around the problem by ‘hoarding’ equipment only exacerbates the problem (Kamel Boulos and Berry, 2012, p. 4). Equipment searches translate into delays for the overall process and have adverse impact on total productivity. By using a RTLS, healthcare facilities can limit their purchases and avoid owning more equipment than necessary. Lower capital expenditure will yield a reduction in the cost of depreciation, whereas fewer assets require less storage and maintenance. It will also help avoid unnecessary rental equipment and machinery. Accordingly, due to RTLS’s ability to locate assets more effectively, medical staff can focus on their professional duties, thus increasing productivity and overall staff satisfaction (Yu, Ray and Motoc, 2008, p. 368).

But RTLS not only improves asset utilization, it was also found to be of great help in improving patient and operational processes by actively monitoring asset and patient flow through the hospital. Thus, RTLS can also save costs and improve patient satisfaction (Wicks, Visich and Li, 2006, p. 7). Benefits occur through minimizing non-value-added activities and reducing on-hand inventory at distributed storage locations (Kumar, Livermont and McKewan, 2010, pp. 45–46). First, RTLS helps in identifying bottlenecks in order to tailor appropriate solutions for typical problems; such as increased waiting times, postponed surgeries, and the lack of beds in an ICU (Berg, Longley and Dunitz, 2019, p. 56). By monitoring flow and handoffs between departments and people, the hospital management can decide if there is a need to assign

Knowledge

1

Persuasion

2

Implementation

4

Decision

3

Confirmation

5

more staff or equipment to specific departments at various stages of the patient pathway (Malik, 2009, p. 19).

Considerations about the economic profitability of RTLS are fueled by the decreasing costs of RTLS hardware and software, especially of tags (Kaplan, 2018; Thau, 2017).

In 2003, a RFID tag was priced at around USD 1. Whereas they now sell for approximately 10 cents (Thau, 2017). Mass production of tags has resulted in a steep decline in prices. Both the cost of hardware and software has been declining at an average of 8-10% p.a. (MarketsandMarkets, 2014, p. 58).

However, even though the costs of most of the RTLS products are falling, the total costs of ownership of a RTLS is very high (Wicks, Visich and Li, 2006, p. 6). Installation costs range between USD 2 to 5 million (MarketsandMarkets, 2018, p. 45), which includes the initial software and hardware, maintenance costs, and additional training for the staff. RTLS requires not only tags and readers, but also additional servers, databases, middleware, and end-user applications. The substantial initial investment seems to be one of the key restraining factors hindering RTLS’ adoption in healthcare facilities (MarketsandMarkets, 2015, p. 57).

3.2.2 Compatibility Safety

RTLS’ applications are highly compatible to a key goal of medical institutions, hospitals and pharmaceutical companies: patient and staff safety. They have been used to track the physical movement of patients to ensure their safety. For example, in the case of Alzheimer and dementia patients; if the patient leaves a defined area or gets too close to potential exits, the system will alert staff and pinpoint the location of the patient (Kamel Boulos and Berry, 2012, p. 4). Moreover, RTLS improves the accuracy of patient identification (Cavalleri, Morstabilini and Reni, 2004, p. 3281). Alerts can warn providers of possible human errors, such as leaving items inside a patient’s body during surgery or when patients take the prescribed medication incorrectly (Lorenzi, 2011, p. 39). Furthermore, RTLS can also improve staff safety by giving them the ability to request emergency assistance in crisis situations (Kamel Boulos and Berry, 2012, p. 5).

Nurses have unacceptably high levels of exposure to violence, which commonly includes verbal abuse but also physical abuse (Chapman et al., 2010, p. 2066). RTLS could help in the timely summoning of assistance.

However, the surveillance possibilities of RTLS can be perceived as ‘Big Brother’ by the hospital personnel and the patients. Without a clear rationale, the system is not compatible with people’s existing values of privacy (Fisher and Monahan, 2012, p. 710).

Union members complain that RTLS can be used to monitor specific employees unfairly such as their break time and working hours tracked. The strong potential resistance may jeopardize an entire RTLS implementation (Fisher and Monahan, 2012, p. 710;

MarketsandMarkets, 2018, p. 45).

Technology

The increasing technological advancements in RTLS during the last two decades have led to improved accuracy, higher efficiency, and lower cost to match the customer’s expectations. Teething troubles such as short battery life of tags have been ruled out almost completely (Fisher and Monahan, 2012, p. 708). Installation time has decreased, reconfiguration of the system has been eased, and moving the application from the

hospital to the cloud removed the complexity of maintaining an on-site installation (Lorenzi, 2016, p. 36). Moreover, a range of hybrid solutions have emerged to tackle some of the major obstacles associated with a single technology based RTLS.

Technically, two or more technologies are now combined aiming to be cost-efficient without having to compromise on accuracy (MarketsandMarkets, 2018, p. 46). For example, Wi-Fi is combined with infrared since it can penetrate through walls and floors but fails to pass through glass sliding doors and windows, which infrared is capable of.

However, some technical issues remain. At the moment, the majority of end users of RTLS in healthcare are not pleased with the implementation, since performance-delivered and performance-promised differs widely (Okoniewska et al., 2012, p. 674).

For example, the accuracy of Wi-Fi promised by vendors is between 5-15 meters.

Unfortunately, in 7 out of 10 cases they fail to achieve this standard (MarketsandMarkets, 2018, p. 46). Likewise, designing hybrid solutions that try to satisfy high accuracy, high range, low power consumption, and low price imposes inequitable trade-off challenges for the vendors, which to date they have not been able to solve completely. Furthermore, the interference of RTLS with the hospital’s medical devices and equipment, especially when they share the same frequency or are used in dense wireless networks, remains a problem (van der Togt et al., 2008, p. 2884).

3.2.3 Complexity Standards

Successfully established standards are a prerequisite for any data exchange (Perlin, 2016, pp. 1667–1668). In the past five years, initiatives have been taken from different organizations and companies such as ISO/IEC (Switzerland), ANSI (U.S.), ETSI (France), and IEEE (U.S.) to establish available standards to agree upon (MarketsandMarkets, 2014, p. 54). Standards like ISO/IEC 24730 and IEEE are a step forward to ensure common standards and interoperability in the market.

However, there is still a definite lack of well-defined technology standards in the market (Technavio, 2016, p. 24). The missing standards make it difficult to integrate available solutions in existing IT landscapes and with each other. Most vendors only rely on a single protocol. Therefore, a variety of different technologies has risen that operate on non-interoperable protocols and frequency bands. Deploying a RTLS project is highly complex and requires a lot of engineering know-how and bespoke on-site adjustments.

The vendor has to be present at the customer’s site during the whole project and must provide adequate training for the hospital’s staff (Lorenzi, 2011, p. 40;

MarketsandMarkets, 2018, p. 45).

3.2.4 Trialability

Although vendors offer pilots and demos of their RTLS offerings, trialability is highly limited. Pilots are typically departmental and do not look at the full benefit than can be achieved at the enterprise level (Hoglund, 2011, p. 21). Demonstrations can only show what other facilities have achieved and what the potential customer might be able to expect from an implementation of RTLS. However, every hospital is different, so each deployment of RTLS must be tailored to the individual hospitals’ needs and objectives, hence a thorough assessment must be completed before any experiments with the

technology can take place (D'Souza, Ma and Notobartolo, 2011, p. 6; Kamel Boulos and Berry, 2012, p. 6). Moreover, the proprietary nature of the RTLS marketplace makes it near-impossible to switch your RTLS provider at a later stage of the project; for example, it is difficult to switch RTLS providers when you want to upgrade your system with offerings from a different vendor (D'Souza, Ma and Notobartolo, 2011, p. 42).

3.2.5 Observability

Many hospitals across the world such as Piedmont Healthcare, Florida Hospital, UT Medical Center, Palmetto Health, Altru Health Systems, Texas Health Resources, Mount Carmel Health, Oklahoma University Medical Center, and Denver Health are using RTLS for a variety of purposes (MarketsandMarkets, 2018, p. 42; Poshywak, 2013, p. 57). Since most of the providers publish their experiences in journals, observability of implementations is present to an extent. Moreover, the increasing use of tags (Technavio, 2016, p. 21) is also noticeable within hospitals from patients, staff, and management of competing health care facilities. However, the advantages of RTLS are hardly visible to others, since the insights from technology are only displayed in the very narrow environment of healthcare facilities and do not target the individual rather the physicians and hospital management. The findings are summarized in Figure 10.

Figure 10: Summary of RTLS’ perceived Attributes of Innovation

Attribute Driver Challenge

Compatibility Technological advancements Technological issues

Safety increase Privacy issues

Already existing Wi-Fi network to build on

Low quality of Wi-Fi network

Complexity Implementation of standards System incompatibilities and necessity of training Trialability Pilots and Demos RTLS = High involvement products,

bound to one vendor equipment and people, has been shown in several case studies in the healthcare sector (Poshywak, 2013, p. 57). However, the diffusion of the technology lacks behind the ambitious expectations 10 years ago. This paper evaluates current market trends and characteristics of the RTLS technology to assess why there has not been a widespread adoption of the solutions in healthcare, and to determine the stage of adoption the technology is in at current state.

A suitable underlying framework for the process of adopting new innovations was adapted from Rogers’ ‘Diffusion of Innovations’, which is also among the most popular and most used in the field. It was shown that both innovators and early adopters have found the innovation to be appealing, but the early majority seems to be more resistant