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Rose-Hulman Institute of Technology, Indiana, USA Uppsala University, Uppsala, Sweden February 12, 2018

Positioning - Requirements and Opportunities within Healthcare


Positioning - Requirements and Opportunities within Healthcare

Contributing Authors Tobias Andersson

Uppsala University

Chauncey Becker

Rose-Hulman Institute of Technology

Audra Christophersen

tobias.andersson.6551@student.uu.se

University of Michigan

chauncey.becker@rose-hulman.edu achr@umich.edu

Samer David

Uppsala University

samer.david.7817@student.uu.se

Faisal Fiaz

Uppsala University

fiaz716@gmail.com

Tyler Frantom

Rose-Hulman Institute of Technology

tyler.frantom@rose-hulman.edu

Fredrik Hiding

Uppsala University

fredrik.heiding.9620@student.uu.se

Haley Heshelman

Rose-Hulman Institute of Technology

haley.heshelman@rose-hulman.edu

Carlo Kovacevic

Uppsala University

carlo.kovacevic.7090@student.uu.se

Petter Larsson

Uppsala University

petter.larsson.3711@student.uu.se

Lidong Liu

Uppsala University

lidong.liu.8145@student.uu.se

Joshua Lovins

Rose-Hulman Institute of Technology

joshua.lovins@rose-hulman.edu

Benjamin Lyon

Rose-Hulman Institute of Technology

benjamin.lyon@rose-hulman.edu

Haubir Mariwani

Uppsala University

haubir.mariwani.2039@student.uu.se

Adrian Moradi

Uppsala University

adrian.moradi.0662@student.uu.se

Josh Nevers

Rose-Hulman Institute of Technology

josh.nevers@rose-hulman.edu

Joseph Novosel

Rose-Hulman Institute of Technology

joseph.novosel@rose-hulman.edu

Shahin Sateei

Uppsala University

shahinsateei@outlook.com

Fahad Shakeel

Uppsala University

fiaz716@gmail.com

Rui Su

Uppsala University

rui.su.0652@student.uu.se

Zhaoyuan Sun

Rose-Hulman Institute of Technology

zhaoyuan.sun@rose-hulman.edu

Albin Sundqvist

Uppsala University

albin.sundqvist.8190@student.uu.se

Milad Taba

Uppsala University

milad taba@hotmail.com

Seiji Takagi

Rose-Hulman Institute of Technology

seiji.r.takagi@rose-hulman.edu

Yue Wang

Uppsala University

yue.wang.8760@student.uu.se

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Positioning - Requirements and Opportunities within Healthcare

Course Faculty Dr. Ëš Asa Cajander

Uppsala University

asa.cajander@it.uu.se

Dr. Mats Daniels

Uppsala University

mats.daniels@it.uu.se

Diane Golay

Uppsala University

diane.golay@it.uu.se

Dr. Cary Laxer Dr. Anne-Kathrin Peters

Rose-Hulman Institute of Technology Uppsala University

laxer@rose-hulman.edu anne.peters@it.uu.se

Client Akademiska Sjukhuset – Uppsala University Hospital

Uppsala, Sweden

2

www.akademiska.se


Positioning - Requirements and Opportunities within Healthcare

Abstract Within the healthcare industry, the accounting for physical assets is both necessary and challenging. This study has been conducted to find possible solutions to the problem of tracking and positioning people and equipment in a healthcare environment. The main challenge to be considered is how one can increase the level of efficiency within the healthcare industry. Efficiency is a crucial part in a healthcare environment, thus there is a high demand for systems that facilitate the ability to position both people and equipment. By decreasing the amount of time that hospital personnel spend on searching for people and/or equipment in the hospital you can increase the amount of efficient worktime. The two major categories of capital are people, those who interact with the healthcare facility, and the equipment, items that interact or belong to the healthcare facility. Within these two categories, subgroups exist that require varying levels of granularity with respect to precision and frequency of data collection. Empirical data was gathered through conferring with Uppsala Academical Hospital staff and observing the hospital’s day-to-day practices, the information was gathered to design a system of constraints to focus our suggestions for potential technologies. Once the constraints were identified, we considered existing solutions designed by consulting companies as well as researching developing technology to ensure no solution was overlooked. The project was divided into several smaller groups to research a broader spectrum of solutions and constraints such as ethical dilemmas, regulations and conflicting technology already implemented in the hospital. The information from our research is presented so that hospital staff can bid the system implementation to several providers, enabling the hospital to allocate resources more intelligently, and empower hospital employees to spend more time assisting patients instead of locating resources.

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Positioning - Requirements and Opportunities within Healthcare

Sammanfattning Att ha uppsikt ¨ over resurser inom sjukv˚ arden ¨ ar b˚ ade n¨ odv¨ andigt och utmanande. De tv˚ a huvudsakliga resurserna ¨ ar m¨ anniskor, sjukv˚ ardspersonal och de som interagerar med sjukv˚ arden, och saker, objekt som tillh¨ or sjukv˚ arden. Inom dessa tv˚ a kategorier finns det ¨ aven diverse undergrupper som har olika krav g¨ allande niv˚ a av precision och datainsamling. Genom att samr˚ ada med sjukhuspersonal p˚ a Akademiska sjukhuset i Uppsala och observera sjukhusets vardagliga arbetsuppgifter, har information samlats f¨ or att framh¨ ava vilka krav sjukhuset har kring positionering.N¨ ar kraven v¨ al identifierats, anv¨ andes dessa som bas f¨ or f¨ orslag till potentiella teknologier. F¨ or att s¨ akerst¨ alla att inga potentiella teknologier f¨ orbises, ¨ overv¨ agdes b˚ ade existerande l¨ osningar utformade av konsultbolag samt teknologier fortfarande inom utvecklingsfasen. Informationen fr˚ an unders¨ okningen presenteras p˚ a ett s˚ adant s¨ att s˚ a att sjukhuset har m¨ ojlighet genomf¨ ora f¨ orhandlingar med diverse tekniska leverant¨ orer. Detta i sin tur kan leda till att sjukhuset kan allokera resurser p˚ a ett smartare s¨ att och g¨ ora det m¨ ojligt f¨ or personalen att spendera mer tid p˚ a att hj¨ alpa patienter ist¨ allet f¨ or att lokalisera resurser.

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Positioning - Requirements and Opportunities within Healthcare

Contents 1 Introduction

7

1.1

Asset Tracking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7

1.2

Dilemma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7

1.3

Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7

1.4

Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8

1.4.1

Study Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8

1.4.2

Interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8

1.4.3

Informal Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9

2 People

10

2.1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10

2.2

Target groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10

2.3

Caregivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10

2.4

Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11

2.5

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11

3 Equipment

12

3.1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12

3.2

General overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12

3.3

Current Tracking Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12

3.4

Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12

4 Data Security and Regulations

14

4.1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14

4.2

General Data Protection Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14

4.3

Personal Data Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15

4.4

Current Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

16

4.5

Developing Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17

5 Technology 5.1

5.2

18

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18

5.1.1

Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18

Barcode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18

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Positioning - Requirements and Opportunities within Healthcare

5.3

RFID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20

5.4

Wi-Fi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20

5.5

Bluetooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21

5.6

Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21

5.7

Infrared . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21

5.8

Vending Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21

5.9

Machine Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

22

6 Previous Implementations

23

6.1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

23

6.2

Johns Hopkins Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

23

6.3

UC San Diego Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

24

7 Conclusion

26

8 Recommendations and Future Work

27

9 Acknowledgements

28

10 References

29

Appendices

32

A Q&A from Presentation to Uppsala University Hospital

32

B Initial Study Visits at Uppsala University Hospital

33

C Interviews with Uppsala University Hospital Staff

37

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Positioning - Requirements and Opportunities within Healthcare

1

Introduction

1.1

Asset Tracking

Implementing tracking of people and equipment in hospitals can be a troublesome and expensive task if not executed correctly. Problems that could arise include the cases where different equipment struggle to function due to disturbance caused by tracking signals, cases where the employees are forced to work in an inefficient way in order to make the tracking possible etc. Although tracking offers surveillance, it will not prevent equipment from disappearing. Should the hospital be able to track equipment outside of the hospital area? This is one of many questions that hospitals must ask themselves. It is important that the tracking system(s) are surrounded with well-known rules and regulations, as well as efficient methods.

1.2

Dilemma

Uppsala University Hospital tasked the project team with investigating the possibilities for tracking its assets. These assets ranged from surgical instruments to ambulances and from doctors to patients. The number of constraints for each asset turned the simple idea of locating an asset into a complex logistical, legal, and ethical dilemma. This report will dive into the possibilites and limitations of tracking hospital assets. The topics that will be featured are how the people that worked on the project were organized, how the problem was broken down into smaller categories and how these were approached, extensive information on each category, previous/existing implementations of this kind of tracking, a conclusion, future work and lastly there will be acknowledgements to the people from both the hospital and the university that made this project possible and provided help and feedback throughout the process.

1.3

Context

The project was presented by Uppsala University Hospital staff to students from Uppsala University and RoseHulman Institute of Technology as part of a course in global computing and working in society. The project team was comprised of fifteen Uppsala University students, and nine Rose-Hulman students. The team was broken into two groups. The first group, referred to as “people”, focused on human assets such as medical personnel and patients. The other, referred to as “equipment”, focused on physical assets such as equipment and supplies. “People” was further divided into a subgroup, referred to as “people-ethics”, which focused on the ethical and legal considerations of tracking people. The subgroup referred to as “peopletechnology” focused on the technologies that could be used for tracking people. “People-ethics” focused on understanding the legislation that surrounds tracking individuals, including who could be tracked, to what

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Positioning - Requirements and Opportunities within Healthcare

accuracy, for what purpose, and the required security for the tracking data. Additionally, they looked into public and user sentiments surrounding the idea of tracking. “People-technology” examined non-invasive tracking of individuals, tracking granularity based on needs as determined through the interviews, and technologies that could be utilized. “Equipment” was subdivided similarly to “people.” “Equipment-ethics” researched security in addition to ethics. “Equipment-technology” had to understand the complexities of medical devices and equipment; some of the location systems have properties that could interfere with medical devices’ operation. To reduce duplicate research, these four subgroups utilized an online database for sharing information. The team distilled this information in a report and a presentation for hospital staff.

1.4

Method

This project gathered data from several sources, primarily: (a) study visits, (b) interviews, and (c) informal research. 1.4.1

Study Visits

Nine study visits were conducted at the hospital, involving a variety of staff (see Appendix C). The team was divided into small groups of three to four people, each assigned a hospital ward: Reception, Equipment Maintenance and Location, Supply Chain Management, Operating Room Management and Sterilization, Rehabilitation, and Surgical Care. The study visits consisted of observations and informal interviews. The data and findings were recorded in a shared Excel sheet. During this phase of the project, the team was in the information-gathering stage. The objective of these first study visits was to gather information to get an initial understanding of each wards process. The study vistis gave us insight to help narrow the project scope. After the study visits were conducted and the observation and interview data was digitialized, the team reviewed the data together, looking for trends and common issues between the different departments. 1.4.2

Interviews

Four individuals of different affiliations with the hospital were interviewed (see Appendix B). These interviews were conducted with individuals involved in the hospital community: The Medical Technology Hospital Physics and IT Department, The Swedish Heart and Lung Association, The Department of Surgical Sciences, and Hospital Management. The interviews were structured to ask questions regarding tracking logistics and the individual’s experiences. Interview topics included problems in day-to-day operations, opinions about potential technologies that could be used, the value these technologies would provide, and potential issues that staff members could foresee.

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Positioning - Requirements and Opportunities within Healthcare

Each interview had a designated person to take notes. These notes were recorded in a shared folder between the team. At this point in time, the project was well on its way. The team had been working on the project for over a month and had been in the midst of collecting data from informal research. The interview data was reviewed with all of this in mind. 1.4.3

Informal Research

When gathering information for the project, the team looked at various sources, mainly scientific journals and government data such as the european General data protection regulation and the swedish Personal Data Act. A lot of the research focused on technologies that have already been implemented by other hospitals or technologies that are applicable to our project. Most of the information gathered was from the internet and from direct contact with the hospital staff.

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Positioning - Requirements and Opportunities within Healthcare

2 2.1

People Introduction

In this chapter the various groups of people of relevance are discussed and what their respective role in the project meant. Each category has their tasks described and their opinion on tracking and to what use it could be in their daily work routine.

2.2

Target groups

The human assets around the hospital were divided into three categories based on differing tracking needs: caregivers, patients and others. These three groups were selected because they represent three levels of tracking detail. Caregivers included doctors, nurses, volunteers and other medical staff; this group of people needed to be found more readily than others and could use a higher level accuracy when being tracked. Patients were further categorized by their age, severity of condition, and ward of care, and the need for tracking them would differ depending on their subdivision. The others group included support staff and visitors, who required significantly less tracking. While tracking these groups has been shown in other hospitals to be beneficial, it is vital to consider the ethical, legal, and security issues surrounding the tracking of people to implement an effective locating system.

2.3

Caregivers

Included in the caregiver group were doctors, nurses, volunteer staff, and technical medical support staff. Based on the information gained through the interview process, the goals of tracking these individuals were to ensure timely care, help improve doctor and nurse distribution, and increase overall efficiency. Interviewees identified that caregivers should only be tracked when they are inside of the hospital. Exact location tracking was only suggested for surgeons, specifically in the emergency ward due to the time-sensitive nature of their work. The current system for locating surgeons involved a long list of phone numbers posted on the wall. Surgeons in this ward often leave to assist elsewhere when there was no pressing task. This led to a delay in responses to life threatening situations that required their presence. A counterpoint to the surgeons having exact location data came from an interview with the Chief Physician at the Department of Gastrointestinal Surgery, Jakob Hedberg. Dr. Hedberg did not necessarily feel the need to track employees, including surgeons, within his department. While they did have unscheduled surgeries, none were time sensitive. However, he did not say that implementing a system with exact locations for surgeons would impede the process. Doctors and surgeons should have real-time, exact location data, but the same was not true for nurses, volunteers, and technical

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Positioning - Requirements and Opportunities within Healthcare

medical support staff. Individuals who fall into the latter group can be tracked based simply on what ward/area they are in as opposed to exact location, since their duties are not as time-sensitive as the surgeons’.

2.4

Patients

As with caregivers, different types of patients required varying levels of tracking. Dr. Hedberg broke patients into two categories: inpatients, individuals who stay overnight, and outpatients, those who do not. Inpatients were patients recovering from emergency services who had travelled through several wards before being cleared to return home. Outpatients came for a routine check up, to receive vaccinations, or to follow up after a procedure. In this category the main areas of scrutiny were time and location of check-in. With many entrances to the hospital, patients have become confused or lost when trying to get to the correct ward. This was also a sentiment expressed by the volunteers in reception. According to Birgitta Wallgren, Development Director of the Neuro Division of Uppsala University Hospital, brain damaged and psychiatric patients required the most accuracy and frequency of location data. These patients have been housed in the psychiatric ward, and Wallgren admits it was alarming how often they have left without clearance. Occasionally, patients from the psychiatric ward have been allowed to walk around the city to help ease them back into society. However, staff have often had to search for patients that have forgotten to return to the hospital after going for a walk. This type of out of facility location data would require additional systems to function that would not be covered for the average inpatient.

2.5

Other

The last category consisted of support staff and admitted patients’ relatives (visitors). Based on interviews with volunteer staff, the intended goal for tracking maintenance staff was to allocate time more efficiently. In the volunteers’ case, these resources were most valuable when it came to recovering wheelchairs. The volunteers had to search the facility and then push several chairs back by themselves. If the location of the maintenance crew were known, the nearest personnel would be able to assist in this process. When it came to tracking visitors, the sentiment from interviewees was that tracking should be no more invasive than check in, check out, and ward changes. This was to keep a tally of the total number of people in a ward, but more importantly individuals could be notified if they were close to a patient with a contagious illness. Overall, anyone who falls into this category would not need exact location and tracking data.

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Positioning - Requirements and Opportunities within Healthcare

3

Equipment

3.1

Introduction

The following chapter desribes the equipment that are used by the hospital in which everything ranging from amount of pieces, current tracking systems that are in place to the actual critera that said equipment needs to fullfill.

3.2

General overview

Uppsala University Hospital desired the tracking of medical equipment and supplies upon arrival and during allocation throughout the campus. Wheelchairs, stretchers, medications, surgical equipment, and various biometric monitors were examples of equipment that must be overseen. The Medical Technology and IT departments of the University Hospital were responsible for roughly 10,000 pieces of equipment. Every two to three years, pieces of equipment are to be returned for maintenance; this maintenance schedule is how the Medical Technology and IT departments discovered when equipment was missing.

3.3

Current Tracking Systems

Some wards have a specialized system for tracking their equipment. The sterilization team has a system of checkpoints where every item is scanned into the system at each stage of the sterilization process, and again once it is returned to the operating room. After use, it is immediately sent directly through the sterilization process again. The unit’s process has been effective in tracking their equipment, but delays the process of preparing an operating room for the next surgery.

3.4

Criteria

An example of assets that needed to be tracked were wheelchairs. Each entrance kept a stockpile of wheelchairs, and wheelchairs were often moved without being returned. A locating system would alleviate the need to manually search through buildings to find missing wheelchairs. At some points they were even completely removed from the building, but without a locating system they were unable to know if the wheelchairs were completely gone. Another challenge was tracking medical supplies from when they were ordered to when they arrived at the destination ward. Medical staff only knew that they ran out of supplies when they checked for it. When they ordered a resupply, they could not be certain that it would end up at the right ward.

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Positioning - Requirements and Opportunities within Healthcare

With the implementation of tracking systems for medical equipment and supplies, said information can be used to improve allocation of equipment around the hospital. For instance, interviewees indicated that insulin pumps are used in multiple wards; however, not all wards have the same need for insulin pumps, shown by the trend of pumps being taken from one ward to another. A tracking system for medical equipment would be able to identify which wards have a greater need for insulin pumps and which wards have less need, allowing the Medical Technology department to formally reassign insulin pumps to those wards with a greater need.

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Positioning - Requirements and Opportunities within Healthcare

4

Data Security and Regulations

4.1

Introduction

Persons who are tracked must be informed of their tracking and must be protected against misuse of their location and tracking data. The laws that apply include the General Data Protection Regulation and the Personal Data act. In this section the laws mentioned above will be explained. It will also cover what failure of compliance with these laws would ensue and how these laws affect the development of a system which handles tracking data of people.

4.2

General Data Protection Regulation

The General Data Protection Regulation (GDPR) defines how government, businesses and organizations may use a person’s personal information. This regulation is important for the healthcare industry as it contains safeguards designed to ensure that personal data is not susceptible to attack or misuse. It was recently developed in the European Union (EU) and will have a high impact on the healthcare sector when it comes into effect in 2018 [1]. The GDPR details that properly informed consent requires “disclosure of all necessary information that a reasonable person would use in making an informed decision, in a format that is readily understandable to the individual, and without coercion influencing choice” [1]. Information required by law for disclosure would include the reasoning, processes, and instruments of the tracking. Written consent was highly recommended to avoid potential regulation breaches. Access to the tracking data should be on a need-to-know basis; doctors and similar healthcare professionals should be the only individuals with access to a patient’s data. The GDPR has a special section concerning personal healthcare data. Below is a quote from the GDPR defining personal data: ”Any information relating to an identified or identifiable natural person (data subject); an identifiable natural person is one who can be identified, directly or indirectly, in particular by reference to an identifier such as a name, an identification number, location data, an online identifier or to one or more factors specific to the physical, physiological, genetic, mental, economic, cultural or social identity of that natural person” [6] The GDPR defines three healthcare specific data types. Health Data is individual data that can relate to the mental or physical health of a person. This includes data from health care services, which can reveal information about the person’s health [6]. Genetic data is individual data relating to acquired or inherited genetic characteristics of a person and can lead to unique information about the health or physiology of that person

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Positioning - Requirements and Opportunities within Healthcare

[6]. Biometric data is individual data resulting from specific technical processing relating to the physiological, behavioral, or physical characteristics of a person, such as an image of a person’s face [6]. These three types of data will have higher requirements of protection than regular personal data, which makes them even harder to manage. These kinds of data are illegal to collect unless one of the several presented conditions applies [6]. The person being tracked must give explicit consent before the data can be processed. There must be reasons for processing the personal data; for example, the processing of data being necessary for a medical diagnosis or assessment of working capacity. Data processing is necessary for protecting against cross-border threats to health and therefore allowed for matters of public health and safety. These conditions are only a small fraction of all the conditions in the GDPR, but as with all regulations, they are subject to change with the passing of time and the invention of new technologies. These three data types and conditions of the GDPR mean that the processing of health data will be more difficult for the healthcare sector [6]. Security and data protection protocols for each subgroup will also be discussed.

4.3

Personal Data Act

The Personal Data Act (PDA), ratified by the Swedish Data Authority, relates to collection, registration, storage, processing, disclosure by transfer, compilation, and joint processing (all of which will be hereafter collectively referred to as processing) of personal data [2]. The Personal Data Act (PDA), ratified by the Swedish Data Authority, relates to collection, registration, storage, processing, disclosure by transfer, compilation, and joint processing (all of which will be hereafter collectively referred to as processing) of personal data [2]. As of the writing of this report, the PDA is currently dictates how personal data should be handled, but the GDPR will be enforced on May 25, 2018. In this act personal data refers to any kind of information that can directly or indirectly refer to a currently living person. The PDA outlines a number of roles including a controller of personal data (controller), personal data assistant (assistant), and personal data representative (representative). A controller is defined as a person who alone or with others decides how and why the personal data is to be processed, an assistant is a person appointed by the controller and processes the personal data on their behalf, and a representative is a person assigned by the controller to ensure that data was processed in a lawful manner. Consent for personal data processing is defined in literature published by the European Union as ”any kind of voluntary, specific, and unambiguous expression of will that can either be in writing or verbal, must be voluntary, and can be revoked at any time” [1]. Sections 17 and 18 of the Personal Data Act pertain directly to processing personal data in health and hospital care. Section 17 allows for sensitive personal data to be provided to a third party with the consent of the registered person. Section 18 explicitly states that sensitive personal data may be processed “for health and hospital care purposes, provided the processing is necessary for

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Positioning - Requirements and Opportunities within Healthcare

a). preventive medicine and health care, b). medical diagnosis, c). health care or treatment, or d). management of health and hospital care services” [2]. If that data was justified using one of the aforementioned reasons listed in Section 18 of the Personal Data Act and does not violate any other Swedish law in place, it would be possible to track healthcare and hospital patients with their consent and process that data accordingly.

4.4

Current Compliance

The team assessed Uppsala University Hospital’s legal and security standards. They spoke with Joachim Perssor, IT Solutions Manager for the Electronic Patient Journal (EPJ) at Uppsala University Hospital and Uppsala County. He said that the current stage of GDPR in Sweden was survey and evaluation. Sweden has its own plans in constructing a national eHealth system, which means it may not be highly interested in GDPR. However, stricter rules are inevitable, and there is no way to get around them. He went on to say that unfortunately, the government has provided little or no guidance for developers to follow GDPR. Existing eHealth systems in some Swedish regions do not meet the requirement of PDA because of the cost of upgrading systems to the protocols. They are still in existence due to their large number of users and the potential risk of chaos if they are shut down. Keeping Perssor’s comments in mind, the team created a list of four security issues on which the system would need to focus: protection against digital attacks, secure distribution of information, proactive protection mechanisms against theft, and an airtight action plan in the event of a data breach. Some of these functions are explicit in the GDPR, which requires each company or organization to assign someone to take responsibility for data protection compliance. The EU gives its guidance in Article 29 to assess where data protection compliance will sit within the organization’s structure and governance arrangements [1]. The EU also specifies that in the event of a data breach, organizations have to report it to their supervisory authority within 72 hours after becoming aware of the data breach (Article 33) [1]. Individuals have to be notified if they were negatively impacted by the attack (Article 34) [1]. The data processor will have to notify the controller without delay after becoming aware of a personal data breach (Article 33) [1]. If the breached data was anonymized, no report is needed (Article 34) [1]. Encryption can anonymize data by rendering the original data unintelligible such that the process cannot be reversed without access to the correct decryption key. According to the GDPR, the key should be kept separate from the anonymized data. If the breached data is not anonymous, the first breach of the GDPR will result in a written warning for non-intentional non-compliance offenses. After a written warning, a company may receive a fine up to 10,000,000 EUR or 2% of the worldwide turnover, whichever is higher. If the company violates the GDPR again, they may receive a fine up to 20,000,000 EUR or 4% of the worldwide turnover, whichever is higher. Companies are also subject to random audits [1].

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4.5

Developing Considerations

Patient data should be handled by a separate system to remove the direct correlation between position data and patient identities, making the tracking and positioning system free of personal data. The hospital should document what personal data it holds, where it comes from, and who should be able to share the information. The latest directive to implement the new General Data Protection Regulation in Uppsala County mentioned a cooperation with other county councils on GDPR. Other organizations that could be collaborated with include the Innovation System (Vinnova) and eHealth Agency. Both of them are responsible for the government plan “envision 2025�, which specifies the future direction of Swedish laws on eHealth. It is also important to consider that the equipment and supplies are connected to the people who use it so data must either be collected in an impersonal manner or secured like personal data.

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5

Technology

5.1

Introduction

A lot of different technologies can be used in order to track objects. In this section, a number of common technologies will be covered in respect to how they work, their advantages and disadvantages, and how they can be used. To facilitate the reading about the technologies, some common techniques for tracking which are used in combination with the technologies are explained below. 5.1.1

Techniques

There are numerous techniques available to determine the position of an object. Closest access point (closest AP or proximity sensing) is a straightforward method where the mobile device adopts the location of the closest access point [18]. Triangulation is a method in which a point’s location can be determined by forming triangles to that point from more than one known location. The position is calculated by comparing the received signal strength (RSS) from multiple access points and then forming angles to the mobile target [13]. With fingerprinting, the location is based on reference measurements saved in a database. The measurements are generally recorded in an offline phase and consist of an information vector and a vector of RSS values received at a specific location. The information vector can contain information such as Cell-IDs or WiFi MAC addresses. As a mobile device moves through space, it compares the received signals with the signals stored in the database, and thus determines its location [18]. Another method of tracking, trilateration, estimates the position of an object based on its distance from more than two reference points to the target object [13].

5.2

Barcode

Symbology is used as a basis for interpreting barcodes. There are a variety of symbologies that are used to communicate between a scanner device and the data from a barcode [8]. Barcodes are a combination of black and white shapes, letters, and numbers. Different barcode encodings affect how the barcode is read by a scanner. In order for barcodes to work effectively, a scanner is needed to document and retrieve information about a certain barcode. There are three different types of barcodes: 1D barcodes, stacked barcodes, and 2D barcodes. 1D barcodes are made up of numbers, letters, and lines, and are typically referred to as linear barcodes. These are used as PostNet barcodes in the U.S. mail system to encode zip codes. They are also used for Uniform Product Code (UPC) in retail stores for managing inventory and checking out [5]. A stacked barcode is similar to a 1D barcode, but it consists of more than one linear barcode stacked on top of one another [7]. Stacked barcodes are useful because they can hold more data than a singular linear barcode. Despite this increase in data storage, the larger a stacked barcode grows, the more difficult it becomes to scan.

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On the other hand, 2D barcodes are more complex than 1D barcodes. 2D barcodes, also known as “matrix codes”, are made up of lines and squares. The major difference in these barcode types is that 2D barcodes can hold more data [27]. 2D barcodes hold more text than 1D barcodes and can also hold different types of information, such as images and videos. Scanners are used to read 1D and stacked barcodes, while imagers are used to read 2D barcodes. Scanners use lasers to read the lines of a linear barcode and require that a barcode be oriented in a specific way in order for it to be scanned [9]. Imagers, however, take an image of the barcode rather than just scanning it. This process allows for barcodes to be more easily checked. Imagers can pick up barcodes that are not flat, like the barcodes on a medication tube [21]. Modern imagers can read both 1D and 2D barcodes. Barcode technology has been used in healthcare primarily to manage patients. When a patient is checked into a hospital, a durable wristband with a unique barcode is assigned to them. Durability is important for both financial and technological reasons [21]. The wristband is designed to last for the duration of the patient’s stay; if the wristband is damaged, the scanner cannot scan the barcode until a new wristband is assigned. This barcode provides information regarding the medical records of the patient, such as the medication they are on, or when their blood was last drawn. It is common to scan the wristband whenever any medical procedure is performed. This minimizes human error and tracks the work of employees [21]. By having caregivers rely on scanning a patient barcode instead of writing down medical information on their own, there is a smaller chance for error. This reduces time spent on documentation and allows caregivers more time to care for the patient. If a nurse administers a drug to a patient, the nurse scans the barcodes of the patient and the medication. This process does several things. First, it ensures that the medication has not already been administered and verifies that it is the correct medication. Second, it documents the information to the patient’s medical record. Third, it documents the employee’s actions. Even though barcode technology is primarily used for managing patients within hospitals, it can also be used for tracking equipment. Tracking equipment via barcode technology is one of the easiest and cheapest technologies. It does require that all the equipment have a barcode, but the barcode can be applied to almost anything. Some examples are respiratory machines, patient monitors, mobile x-ray units, blood bank refrigerators, ultrasound units and diagnostic equipment. Barcode technology is a relatively cheap method to implement and is an established technology. Barcodes reduce human errors by ensuring personnel administer the right medication. It can also be used to document the locations of patients. The objective of tracking equipment is to allow the hospital to know the location in real time. However, barcode technology is dependent on someone manually scanning the equipment everytime it changes location. Therefore, while barcode technology would be a fairly cost-efficient solution and easy to implement, it might not be a solution that fulfills all the criteria the team identified.

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5.3

RFID

RFID (Radio Frequency Identification) uses active or passive tags that broadcast radio signals received by a reader. The reader identifies a tag through its unique serial number and records the information that has been sent. The tag may contain more than just its serial number [16]. When a system using RFID technology is created, a database is often used to store communication between RF transmitters and RF readers, including which RF transmitter interacted with which RF reader. An RFID tag consists of a microchip, an antenna, and possibly a battery, depending on whether it is an active RFID tag or not. Active RFID tags contain a battery to power the microchip. Passive RFID tags generate an electromagnetic field that induces power for the chip. Different RFID tags work on different frequencies. The higher the frequency, the better the transmission speed and range. Frequencies are usually divided into three categories. The first category is Low Frequency (LF), between 30-500 kHz,. The next is High Frequency (HF), between 10-15 MHz, and finally, Ultra High Frequency (UHF), which measures between 850-950 MHz, 2.4-2.5 GHz, and 5.8GHz [16]. RFID technology is able to identify objects that communicate with its tags. An active RFID has a battery in the RF transmitter enabling the transmitter to communicate with the RF reader at a longer distance. The range of active RFID is approximately 30 meters. Active RFID also contains an indicator that shows how strong a signal is. This indicator is called the Signal Strength Indicator (SSI). The RF reader receives the values from the SSI and with these values one gets a clue where the object is located. Vibration sensors can be placed within active RFID tags to detect if the object is in motion. RFID can be used to track both people and equipment [4]. When it comes to patients, RFID tags can be included into a patient’s’ wristbands. This was done at Sanraku Hospital in Tokyo, Japan to ensure injection safety [10]. With equipment, an RFID tag can be included as a built-in part of the equipment to be scanned whenever necessary.

5.4

Wi-Fi

When an indoor positioning system is developed to use Wi-Fi, received signal strength (RSS) indicators are often used to read the power of a Wi-Fi access point. Using this combination of RSS indicators and Wi-Fi is one of the most common fingerprinting positioning (FP) strategies. Wi-Fi is a widespread technology found in most households, industries, and businesses. This means that the technology does not require much investment because the infrastructure is already there [14]. Today, most people in the western world own a smartphone, and most smartphones have Wi-Fi built-in. It is easy to develop software for these mobile devices. When locating different objects with Wi-Fi, it is possible to see where the object is located as long as the object is connected to the system. If people are connected to the system via their computers or mobile phones, this can be a disadvantage from the view of privacy because the person’s position can be determined.

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5.5

Bluetooth

Bluetooth is a low-energy wireless technology used to transfer data over short distances. An advantage of Bluetooth is its low energy consumption, especially Bluetooth’s sibling, Bluetooth Low Energy (BLE). BLE is not to be confused with ordinary Bluetooth, as it uses significantly less power and is used for transferring small amounts of data over short distances. Using BLE, an application can run on a small battery for four to five years. It may not be ideal for phones, but it is suitable for an application that sends small amounts of data periodically. Bluetooth and BLE do not usually interfere with other radio networks or medical devices [15]. Common techniques for positioning using Bluetooth include triangulation, closest access point, and fingerprinting.

5.6

Ultrasound

Ultrasound can be used to track the distance to objects by measuring the delay between transmission and echo of the ultrasound. The time it takes for an ultrasonic wave to travel is called time-of-flight (TOF) [26]. A common technique for calculating the position of an object is ultrasound trilateration. There is not as much commercial use of ultrasound for positioning as Bluetooth. However, it is still used in some systems such as TELIAMADE [20] and 3D-LOCUS [12]. A common factor for these systems is that they have a high focus on accuracy, some even down to the sub centimeter level. Ultrasound-based systems are suitable for systems that require high accuracy, like collision avoidance systems [20].

5.7

Infrared

Infrared badges carry only a small amount of data and transmission occurs quickly, within 1/60th of a second. Each infrared signal transmits a unique identifier that can be both focused and directed. Infrared receptors, which can be focused to allow smaller reception range, are highly sensitive and are equipped to convert light energy to electrical signals. Thus, a single sensor can identify multiple data packet transmissions in a near simultaneous fashion [19].

5.8

Vending Systems

Vending machines for medical supplies do exist; however, few companies exist that produce them for a niche market with minimal competition. Vending machines can automatically track the quantity of supplies they store and contain them in a controlled environment. Some of the machines can also track their supplies by expiration date. Vendtek produces a machine, the “EMS Medic Supply Inventory”, that can be connected to the Internet so that it requests refills of its supplies as its supplies begin to run out, or the supplies are nearing their expiration dates [11]. Vendtek’s system also comes with ID readers and biometric security to restrict access

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to controlled substances. According to Medinstrum, their vending systems can be refrigerated to keep drugs at optimal temperatures; however, their vending machines should not be used to contain ER or other quick-access supplies [22].

5.9

Machine Learning

Machine learning is defined as a computer being able to learn how to perform a task, without being explicitly programmed to do so [24]. A system using machine learning could use data gathered from anywhere. Some examples include: when and where equipment disappears, when and where patients tend to get sick, and which types of illnesses and injuries occur at which areas within the hospital. Compiling all this data and applying a carefully selected algorithm to it may identify potential faults in the hospital’s process. There are several machine learning algorithms the system could use. Machine learning techniques are often divided between the fields of classification and regression. Regression techniques predict a continuous value, like the price of a house given its size and location. Classification techniques predict an attribute, also called a label, from a given set of discrete variables [5]. The system would have more use of classification since the system could predict whether an item were in a certain location or not, or whether an item went missing in a particular area. The label of an item could, for example, be ”present” or ”not present”, which would convey whether or not an item was in a specific position at a certain time. There are several algorithms that can be used for classification; support vector machines (SVM) and K-means classification are good candidates for the system [5].

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6

Previous Implementations

6.1

Introduction

Locating and tracking medical equipment, supplies, and personnel has been a problem for hospitals around the globe, not just Uppsala University Hospital. The different regulation another country has to be considered but it is important to look how others are using the technologies to improve their healthcare. In this section a few tracking solutions implemented by other hospitals will be explained.

6.2

Johns Hopkins Hospital

In 2012, the Johns Hopkins Hospital in Baltimore, Maryland, United States, implemented a real-time location system (RTLS) using a combination of infrared (IR) sensors, RFID (Radio-Frequency Identification), and Wi-Fi locating to keep track of assets and staff throughout its new 150,000 square meter patient facilities [3]. The system that Johns Hopkins decided to use was Versus Advantages from Versus Technology, Inc. [3]. Versus set up a network of IR and RFID sensors with about 1 RFID sensor to every 10 IR sensors. The IR sensors would provide “room-level” location on tagged people and items, while the RFID would add redundancy. Versus laid out the system with with 24 sensors per data collector, a device normally located in the ceiling that would read the location data from the sensors. There would then be four data collectors that would forward on their data to one gateway or data concentrator. All the gateways had a wired connection to a backend system. Versus found that a system that solely used Wi-Fi had a shortcoming: it required too many access points to get an accurate location [25]. Hence, Versus used a combination of the three technologies. The system not only kept track of equipment around the hospital but also helped employees allocate equipment more efficiently. It used real time displays of equipment “par levels”, a leveling system that indicated if there were sufficient pieces of equipment in that area [3]. The color-coordinated display indicated if there were too many or too few of a type of equipment, such as wheelchairs, as well as the status of other areas so equipment could be allocated appropriately. In addition to the real-time displays, the system kept “room rounding logs” that showed how much a piece of equipment was actually used in its assigned area. These logs expressed the usefulness of a piece of equipment in area and would be more effective if allocated elsewhere. The Versus system was tied into the preexisting system for calling nurses at the hospital. A patient would be able to click their call nurse button, and the locating system could identify the nearest free nurse and direct them to help with the patient in distress. The locating system could identify when nurses were busy or treating a patient by their proximity to another patient so they would not be called away, and it would instead go to the next closest free nurse [25]. The real-time locating system improved workflow throughout the hospital and cut down on many delays.

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6.3

UC San Diego Assessment

In 2017, the University of California San Diego Medical Center (UC San Diego) was named one of the United States’s “Most Wired”, in part for its implementation of an RTLS. The title of “Most Wired” has been awarded Hospitals & Health Networks magazine of the American Hospital Association to hospitals and health systems “that excel in using information technology (IT) to advance patient care and population health, protect the privacy and security of patient information, and bring greater efficiencies to operations” [17]. The type of RTLS that UC San Diego implemented involved putting active tags on some items, while using passive tags and “par levels” similar to Johns Hopkins’ for the others. In an interview with Becker’s Hospital Review, Scott Sullivan, the department business officer for perioperative services, imaging, and procedures at UC San Diego, spoke about the assessment that he and his team needed to make before implementing an RTLS by outlining seven major considerations [23]. The first of the considerations Sullivan discussed was how the technology helped determine the real usage of equipment around the hospital. He commented that the records on the location of the equipment over time showed that equipment was often taken out for longer than it was actually in use. The issue of holding on to equipment longer than necessary resulted in overestimates of the actual usage of a piece of equipment, which lead to overstocking equipment. Sullivan made a note saying,“With many items, we never knew where they were left during the day. Often, due to reluctance to give up equipment, items would just be sitting, unused on the floor. We would then order another. . . to fill our need because we didn’t think there was one available,” which was a preventable expense [23]. With an RTLS, UC San Diego was able to significantly reduce its excess stock of equipment and save the medical center time and money. However, being able to spot the over-allocation of equipment did not change the situation overnight. This led to Sullivan’s second consideration: that the tracking of equipment necessitated a change in the staff’s culture of handling equipment. The staff not only held onto equipment because they forget to return it, but they also feared not being able to reacquire the equipment when it was needed. Sullivan gave another hypothetical: “For example, if a nurse routinely requests an IV pump from central services department and is routinely told that one is not available, he or she may start storing pumps on the floor so that one is always available” [23]. With the introduction of the RTLS, the central services department needed to rebuild a trust with the staff that the equipment would be available when requested. Sullivan’s third consideration was how the tracking of the equipment reduced the time spent by staff, especially surgical staff, looking for the equipment they needed. This would allow more time to be spent taking care of patients and being productive. However, he commented in his interview that, “Tracking easily misplaced items, like gurneys and IV pumps, can improve processes at a hospital, but if the hospital relies on a location system to do [all] the tracking, processes can once again become inefficient” [23].

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This leads to his fourth consideration, that “It is not necessary to track every piece of equipment” [23]. This idea emerged from Sullivan’s observation that when the staff felt like they were no longer accountable for the equipment, they became lazy about returning and maintaining equipment. Sullivan believed that a better approach was to use “par levels” so staff were still responsible for making sure that equipment gets back to where it belongs [23].Following his line of thought from his fourth consideration, Sullivan’s fifth consideration was that the cost of the item should not necessarily be the deciding factor for whether something should be tracked. Deciding whether an item should be tracked should also be based on its type of usage. For example, Sullivan and his team “tagged the senior nurse’s mobile phone in the emergency department... the tag probably cost more than the phone, but the need is there, especially in the time spent when it is being looked for” [23]. Staff also tagged the portable defibrillators in the emergency room, for the same reasoning, which saved nurses’ time and energy. In Sullivan’s sixth consideration, he suggested that items that have travelled between departments and across multiple campuses should be tracked [23]. This was not solely to make sure that the items get back to their appropriate departments, but also so that the department recognized that it currently had a smaller number of those pieces of equipment than it normally did. Finally, Sullivan emphasized that a medical facility will only be able to achieve the maximum benefit from an RTLS by having facility-wide coverage [23]. Sullivan explained that even if only one department was tracking its equipment, it was important that the network cover the entire campus because “the goal of tracking is to get staff back to patients quicker, part of that is helping our staff return pieces of equipment [wherever they are in the hospital] to their proper place” [23].

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7

Conclusion

The possibilities for an asset tracking or locating system at Uppsala University Hospital are numerous; however, any implementation would need to consider the differing tracking needs of the assets and the complex legal, ethical, and security restraints. The tracking needs of human assets depend on who they are and what they do around the hospital: whether they are a caregiver, patient, or neither. For physical assets, some already had methods of tracking, which could be improved, while others had no system and would disappear for one reason or another. When implementing a tracking system, the hospital must take into consideration laws such as the GDPR and PDA that govern data security to ensure the protection of the persons who are being tracked from misuse of their data. For the tracking system itself, there are various technologies that could be used, each with its benefits and drawbacks, some with more potential than others. Reviewing how other hospitals and medical centers have implemented tracking and locating systems, along with the considerations that they made illustrated the process that Uppsala University Hospital has embarked on.

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8

Recommendations and Future Work

The team explained various tracking-capable technologies in detail, but there are still many other areas to consider. As various techniques and technologies develop further, they may have applications in data tracking, like data science and artificial intelligence. The specific technologies to be used in the system must be decided; e.g. should RFID, Wi-Fi, and Bluetooth be used to track wheelchairs to an accuracy of 50 meters, or should GPS be used instead, to track to an accuracy of 5 meters. Perhaps neither of those options would work. The cost for each technology has not been fully researched; price quotes for tracking systems on the size and scale of Uppsala University Hospital would need to be retrieved from vendors that specialize in healthcare tracking solutions. Designing a single solution was not in scope of this project, so possible implementations would also need to be designed. Implementation details also need to be presented by vendors: details such as how patient and equipment data will be stored to comply with relevant legislation is maintained, how the data will be presented for users, how how users will interact with the interface, how locations will actually be displayed, etc. The physical attachments to equipment such that the attachment does not impede the function of the equipment also must be considered. Some technologies require physical attachments that take up space, for example GPS and Bluetooth hardware, while others require practically no space on the item itself but need fixed hardware somewhere, such as barcode scanning. Paying attention to GDPR and PDA in respect to its legislations and boundaries that will be enforced due May 2018 is also a factor that decides what type of technology, system or type of valid asset have already taken GDPR and PDA into account or will need extra attention in order to make it work for our purposes of tracking healthcare equipment for the hospital. Having a system that orginally does not meet the requirements needed for GDPR and PDA is therefore not recommended and should be concidered carefully before chosen. Additional development resources and these types of changes for GDPR and PDA for any current techonlogy or system will most likely require some development time to make sure everything is in check for the transformation.

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9

Acknowledgements

The team would like to thank Dr. Mats Daniels, Dr. ˚ Asa Cajander, Dr. Anne-Kathrin Peters, and Diane Golay from Uppsala University in Uppsala, Sweden as well as Dr. Cary Laxer from Rose-Hulman Institute of Technology in Terre Haute, Indiana, USA. These faculty provided countless hours of feedback throughout the project; they provided us direction and motivation when needed and possess saintly amounts of patience. Birgitta Wallgren and Magnus Larsson allowed the team the opportunity to conduct research for the hospital. Birgitta and Magnus were always available for questions and were very valuable resources when coordinating with the hospital; many thanks to them. Thank you to the many hospital staff members who the team interviewed. The interviews were invaluable in establishing criteria for the project, as well as how to divide the project. Also, a very special thank you to Helena Bern´ald, who spoke about working together and overcoming cultural differences; her lecture gave great insight into how to effectively collaborate during this project. To each and every one of you, thank you.

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10

References

[1] “General data protection regulation 2016. european union; 2016.” http://eur-lex.europa.eu/eli/reg/2016/679/oj, [Accessed: 2017-10-10]. [2] “Personal data act,” 1998, http://www.wipo.int/edocs/lexdocs/laws/en/se/se097en.pdf, [Accessed: 2017-11-06]. [3] “The johns hopkins hospital case study,” Versus Technology, Inc., 2017, http://www.versustech.com/rtls-case-studies/johns-hopkins-hospital/, [Accessed: 2017-10-24]. [4] A. Y. A. A. N. Shirehjini and S. Shirmohammadi, Equipment Location in Hospitals Using RFID-Based Positioning System, 2012, ch. pp. 1058-1069. [5] E. Alpaydin, “Introduction to machine learning,” MIT Press, 2010, iSBN 978-0-262-01243-0. [6] J. P. Armstrong and A. Bywater, “Absolute software corporation. what healthcare organizations should know about the gdpr,” Absolute Software Corporation, 2017,

https://www.whitepapers.em360tech.com/wp-content/uploads/GDPR-Implications-of-the-GDPR-in-Healthcare-042717 pdf, [Accessed: 2017-10-15]. [7] Atteberry, “How 2d barcodes work,” How Stuff Works, 2011, https://science.howstuffworks.com/innovation/repurposed-inventions/2d-barcodes.htm, [Accessed:

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11-10]. [8] BarcodesInc, “Barcode technology,” https://www.barcodesinc.com/articles/barcode-technology.htm, [Accessed: 2017-10-10]. [9] ——, “Imager barcode scanner,” https://www.barcodesinc.com/cats/barcode-scanners/imager.htm, [Accessed: 2017-10-10]. [10] S. Baum, “5 ways the healthcare industry is implementing rfid technology,” MedCityNews, 2013, https://medcitynews.com/2013/12/5-ways-hospitals-implementing-rfid-tags-emerging-trend-healthcare/, [Accessed: 2017-10-12]. [11] V. W. Equipment, “Medical supply machine,” http://www.vendtek.com/vending-machines/specialty/medical-supply-machine, [Accessed: 2017]. [12] J. C. P. et al, “Performance evaluation of 3d-locus advanced acoustic lps,” 2009, http://www.car.upm-csic.es/lopsi/static/publicaciones/Revista%20SCI/IEEETIMPrieto2009.pdf, cessed: 2017-10-03].

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[13] S. F. et al, “An indoor bluetooth-based positioning system: concept, implementation and experimental evaluation,” 2009, https://pdfs.semanticscholar.org/9f9a/84f89ae5fc5eab6b741436f9ef7fe721d18f.pdf, [Accessed: 2017-09-10]. [14] S. Gao and S. Prasad, “Employing spatial analysis in indoor positioning and tracking using wi-fi access points,” Proceeding ISA ’16 Proceedings of the Eighth ACM SIGSPATIAL International Workshop on Indoor Spatial Awareness, 2016, http://www.geog.ucsb.edu/∼sgao/papers/2016 acmsigspatial isa indoorpositioning.pdf, [Accessed:

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11-07]. [15] Infsoft, “Indoor positioning, tracking and indoor navigation with beacons,” https://www.infsoft.com/technology/sensors/bluetooth-low-energy-beacons, [Accessed: 2017-11-07]. [16] C. Jechlitschek, “A survey paper on radio frequency identification (rfid) trends,” 2006, https://www.cse.wustl.edu/∼jain/cse574-06/ftp/rfid.pdf, [Accessed: 2017-10-07]. [17] C. Johnson and J. Carr, “Uc san diego health named among nation’s ‘most wired,” 2017, https://health.ucsd.edu/news/releases/Pages/2017-07-10-uc-san-diego-health-named-most-wired.aspx, [Accessed: 2017-12-06]. [18] M. A. e. a. Labrador. [19] W. C. Lynch, David K.; Livingston, “Color and light in nature,” Cambridge, UK: Cambridge University Press. p. 23, 2001, iSBN 978-0-521-77504-5. [20] A. D. M, “A comparative analysis on indoor positioning techniques and systems,” 2013, http://www.ijera.com/papers/Vol3 issue2/KF3217901796.pdf, [Accessed: 2017-11-27]. [21] H. Mag, “The role of barcode technology in patient safety and identification,” Health Management Technology, 2012. [22] Medinstrum, “Medical vending machines,” http://medinstrum.com/medical-vending-machines/, [Accessed: 2017]. [23] B. H. Review, “How to use real-time tracking to manage hospital equipment: 7 tips from the university of california san diego medical cente,” 2009, https://tinyurl.com/y9cjjl3k, [Accessed: 2017-12-07]. [24] A. Samuel, “Some studies in machine learning using the game of checkers,” IBM Journal of Research and Development, 1959, dOI 10.1147/rd.33.0210.

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[25] C. Swedberg, “Johns hopkins’ new facility tracks food, assets, staff,” RFID Journal, 2012, http://www.rfidjournal.com/articles/pdf?9513, [Accessed: 2017-12-06]. [26] Terabee, “Time-of-flight principle, measuring the distance between sensor/object,” 2017, https://www.terabee.com/time-of-flight-principle/, [Accessed: 2017-12-05]. [27] A. Vecchione, “Which barcode system is right for you,” Healthcare IT News, 2014, http://www.healthcareitnews.com/news/which-barcode-system-right-you, [Accessed: 2017-11-10].

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Appendices A

Q&A from Presentation to Uppsala University Hospital

Could you use an active RFID tag in scanning sterile equipment in [the] operation theater? Yes, the active RFID would either have to be built into the surgical tool, ensuring that the tool design is still wieldy, or attached to the surgical tool somehow.

If money was not an issue, what would be the best combination of technologies for tracking patients and presenting that data to staff? A combination of infrared, WiFi, RFID, and barcode would be an excellent way to track both people and equipment. This many technologies establishes redundancy while providing a very degree of accuracy. In respect to presenting data to staff, machine learning algorithms could process the information and produce useful insights, such as areas a piece of equipment gets lost and after what particular actions.

Which system do you believe is the most cost effective, reliable, and easy for staff not interested in technology to use in the following areas: Supplies (automatic inventory and requests to fill inventory) Equipment (where equipment is and where it is used) People (time it takes for someone to arrive to a position, time spent in a room, entering “forbidden� areas: escaping patients) The best balance between cost, reliability, and ease of use would be an implementation using RFID and barcodes. Including two technologies ensures system redundancy and would provide a reasonable level of location accuracy. Which specific supplies, equipment, and people get associated with each technology is an implementation detail.

When it comes to incremental implementation of position capability at the hospital, what types of assets would be the number one priority to locate/track and why? Doctors, physicians, and emergency room nurses would be the first individuals to have this tracking system implemented since their jobs focus directly on providing care in emergency situations. An ideal system would reduce the time it takes to contact such personnel, saving what may become a very important few seconds for the patient.

Have you stumbled upon any trends when it comes to standards/protocols within the field of tracking? Yes, with respect to legislation, tracking a person requires that the person is familiar with the method of tracking, why they are being tracked, and their consent to be tracked. For more information on these practices, please refer to the Data Security and Regulations section in the report.

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Positioning - Requirements and Opportunities within Healthcare

B

Initial Study Visits at Uppsala University Hospital

Study Visit with Reception Team Members: Chant Becker, Carlo Kovacevic Question: What assets would you like to have location data for? Answer: Wheelchairs Question: What is your current system for locating non human mobile assets? Answer: Personnel searching the hospital or a hospital wide email. Question: What signs indicate that you are missing an asset? Answer: Patient will request a wheelchair Question: Who is in charge of tracking assets now? Answer: Receptionists Question: How often are you searching for assets? Answer: multiple times per shift Question: How long do you think you think each search averages? Answer: 15-20 minutes Question: How would you like to interact with the system(smartphone, computer, tv screen)? Answer: little to no interaction by receptionists Question: How do you see the final solution operating? Answer: Deposit for taking the chair, similar to how cart returns work in most grocery stores Other Notes: �People can grab them or ask us� Return them to garage Ward patients keep them All entrances have their own stock of wheelchairs They have spare chairs if there is no stock that has to be signed in and out Call to retrieve if missing for extended period Call transportation if no chairs in the area Entrance 70 is the closest door to the garage Elderly/non native speakers get confused on where to go to pick up/drop off Clarify which entrances have wheelchairs and whether any get priority Clarify total number of wheelchairs: Hundreds of chairs All entrances have wheelchairs, though entrance 70 has the most

Study Visit with Equipment Maintenance and Location Team Members: Albin Sundqvist, Faisal Fiaz, Josh

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Positioning - Requirements and Opportunities within Healthcare

Lovins, Adrian Moradi Question: What assets would you like to have location data for? Answer: All electronic medical equipment and hospital beds Question: What is your current system for locating non-human mobile assets? Answer: The delivery service that is supposed to move equipment from one department to another scans barcodes, but people move things from building to building all the time so it isn’t that helpful Question: What signs indicate that you are missing an asset? Answer: When a request for maintenance is sent to a deportment, and the department says they don’t have it. Question: What other data would you like to have tracked? Answer: When equipment needs to go through preventative maintenance again Question: Who is in charge of tracking assets now? Answer: Everyone is in charge of the equipment in their own building, but each ward has control over things in their own department. Question: How often are you searching for assets? Answer: Constantly Question: How long do you think you think each search averages? Answer: Some end quickly, though some end with the item never being found Question: How would you like to interact with the system(smartphone, computer, tv screen)? Answer: Computer program Question: How do you see the final solution operating? Answer: The best solution would be for the individual manufacturers to implement a positioning solution directly into the equipment.

Study Visit with Supply Chain Management Team Members: Haubir Mariwani, Seiji Takagi, Su Rui Question: What assets would you like to have location data for? Answer: Supply levels and the incoming shipments of supplies Question: What is your current system for locating non-human mobile assets? Answer: having someone look around, sometimes they leave a note when they borrow/take out an asset, or by calling around to the different wards. Question: What signs indicate that you are missing an asset? Answer: The departments can’t find the asset when they are looking for it or it doesn’t show up when the ward expects it. Question: What other data would you like to have tracked?

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Positioning - Requirements and Opportunities within Healthcare

Answer: Quantity of supplies used for the purposes of keeping supply quantities from going too low. Question: Who is in charge of tracking assets now? Answer: Each ward is in charge of checking to see if they have received their supplies, how much they have, and keeping track of it. Question: How long do you think you think each search averages? Answer: If the shipment is lost, then a new order has to be made which can take some time, and they often spend hours looking for things that wards need. Question: How would you like to interact with the system(smartphone, computer, tv screen)? Answer: Web-app or computer program Question: How do you feel about personal tracking vs. location? Answer: There is a need for live locating, and tracking could be helpful. Question: How do you see the final solution operating? Answer: Intelligent system watching for when they run out of supplies and then order more. This needs to use predictive measures to ensure backups Other Notes: Most orders that were mentioned in the interview refer to consumable assets (drugs, towels, bedsheets, etc.) The system would need to allow for variations in needs from seasonal, to per patient, to sudden outbreaks System would need to be open to tying into Electronic Health Records Can use system to keep track as used but needs fast access The department is already planning on getting automated “vending� for medications O.R. has a scheduling system but there are a lot of emergency usage Scrubs have built in passive RFID tags.

Study Visit with Operating Room Management and Sterilization Team Members: Tyler Frantom, Petter Larsson, Shahin Sateei, Fredrik Heiding Question: What assets would you like to have location data for? Answer: Surgeons, nurses, anesthesiologists, and movable equipment Question: What is your current system for locating non-human mobile assets? Answer: The Sterilization team already has a system of checkpoints where they scan each group into the system as it moves through the process and the scanned again once it is in the O.R. It then gets sent straight back down to Sterilization Question: What is your current system for locating personnel?

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Positioning - Requirements and Opportunities within Healthcare

Answer: There is a long list with phone numbers in each room and a piece of software for scheduling surgeons. Question: What signs indicate that you are missing an asset? Answer: Either the doctor can’t be found or the item can’t be found prior to the operation. Question: Who is in charge of tracking assets now? Answer: Generally the nurses at the individual stations keep track Question: How often are you searching for assets? Answer: They are constantly looking for surgeons. Instruments almost never go missing Question: How long do you think you think each search averages? Answer: 5-60 minutes Question: How would you like to interact with the system(smartphone, computer, tv screen)? Answer: computer program or an app for doctors Question: How do you feel about personal tracking vs. location? Answer: Tracking doctors needs to be vague enough that exact locations aren’t known Question: How do you see the final solution operating? Answer: They would like to be able to notify the doctor when they are needed and be able to see where the doctor is if they aren’t in the O.R. Other Notes: Sterilization has a method of tracking that keeps exact track of all instruments at every step in the process, but is semi-manual (barcodes) and takes some time to do.

Study Visit with Rehabilitation (specifically brain and spinal cord injuries) Team members: Haley, Fahad, Lidong Question: What assets would you like to have location data for? Answer: Patients (both in and out patient), staff, and equipment Question: What is your current system for locating non-human mobile assets? Answer: None Question: What is your current system for locating personnel? Answer: None Question: What signs indicate that you are missing an asset? Answer: A patient is missing or equipment is not where it was left Question: What other data would you like to have tracked? Answer: The doctor would love to see sensors that can also relay some biometric information from the patients (this is probably outside of the project scope) Question: How often are you searching for assets?

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Positioning - Requirements and Opportunities within Healthcare

Answer: Equipment often, patients less frequently Question: How would you like to interact with the system(smartphone, computer, tv screen)? Answer: Smartphone or sensors, some patients are less capable of using equipment and therefore need a system that requires minimal effort on their part Question: How do you feel about personal tracking vs. location? Answer: Very positive especially for patients who tend to wander out of the ward Question: How do you see the final solution operating? Answer: Sensors of some kind

C

Interviews with Uppsala University Hospital Staff

Interview with Joachim Perssor Interviewers: Lidong Liu and Birgitta Wallgren Date: 10/24

Joachim answered some questions on: GDPR: despite the regulation being launched in 2016, Swedish government started to work on it in early 2017. So the whole process is still at a primary stage, focusing on survey and evaluation. And it seems like Sweden has its own plan in constructing the legal and digital medical system, which means, it does not have a high interest in GDPR implementation. However, strict rules are inevitable and there is no escape from them. Official guidance: Unfortunately, so far, the government has provided little or no guidance for developers to follow GDPR. Sensitive data: If our system contains it necessarily, we should adhere to the laws(GDPR and PDA), but this means more difficulties in development. And it is almost impossible for patient tracking systems as you have to link the identity of the patients with their position data. Development experience: Previous eHealth systems in some Swedish regions actually do not meet the requirement of PDA, as high cost on it during development. The reason why they are still working is due to the large number of their users and the potential risks of chaos if they are all shut down at once. Portability: Portable devices are essential as a trend for eHealth system development. More often, tracking things are easier than tracking people directly.

Interview with Uppsala University Hospital Medical Technology Hospital Physics and IT (MSI) Interviewed: David Stenstad and other Staff Interviewers: Rui Su and Petter Larsson

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Positioning - Requirements and Opportunities within Healthcare

Introduction: This is a department combines three responsibilities, our interviewees focus on medical technology. The main responsibility: provide maintenance for the devices and includes some repair job. They are in charge of about 10000 devices. Every device will come to them for maintenance every three or two years. The major issue that they are facing is that they can’t find certain device and would spend a lot of time searching. If something can’t be found, they will label them as missing and every year there are missing devices. Currently, all the devices are labeled with barcode and they already have a barcode system. However, this system only cover the transportation part of the devices, once the device goes to the ward, they will lose track of the device. Their expectations: Another system other than Medusa, the current system can be provided for them to search for devices. No need for real time information, the information can be updated every 24 hours. Ideally, the transmitters can be built in the devices(very hard to realize). If battery is used for the transmitter, the battery should last longer than the maintenance cycle. The risks in their eyes: If transmitters are used, maybe the function of the devices would be affected. It could be hard to track smaller things. If batteries are used, battery changing can be a problem, since the clinic may not do this. There are many different devices, how to provide tracking services for them all can be hard. When it comes to track things that patient takes home, it could be hard.

Interview with Surgical Staff Interviewed: Jakob Hedberg, Chief Physician at the Department of Surgical Sciences, Gastrointestinal Surgery Interviewers: Adrian Moradi and Audra Christophersen Which hospital personnel do you work most closely with? How do you contact each other? Each patient has a “team:” the responsible doctors and nurses. They communicate via phone call or text on a cell phone (personal vs. work phone). This team, along with the receptionists, should be allowed access to patient location data. Views on tracking people: Personally, he does not see any issues with the current system of locating fellow employees, as they maintain contact via cell phone and rarely wander from their respected ward. Operations are not minute dependant in their department which doesn’t make tracking as important either. He sees the benefit in tracking patients, but has concerns about the ethics and legal aspects. Currently, patients have a bracelet with identification. In-patient tracking: Often wonders where patient is. Are they in recovery? Getting the exam he ordered? Out-patient Considerations: He often wonders where the patients are. Have they checked in? Are they in the seating area? Where in the seating area are they?

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Positioning - Requirements and Opportunities within Healthcare

Views on “things” tracking: He believes tracking things over people is more imperative. A lot of time is wasted in the operating room searching for equipment. Would also be very good for new personnel that doesn’t know where equipment is located. Hospital Visit in Japan: He recently visited a hospital in Japan and was impressed with their system of communicating with patients. Patients received a pager that notified them of when and where to go after they check-in.

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