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Friend or Foe? “Indoor GPS” for Healthcare

July 16, 2015
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Implications of "Indoor" GPS

“Bob, I’m very sorry to share that last month, you most likely gave 4 patients MRSA infections and didn’t appear to have washed your hands prior to having direct contact with each of them. The data for you and all other providers in this organization comes from a continuous, indoor location tracking system. It also knows exactly where the wash sinks and hand sanitizers are. You didn’t appear to have stopped at any of them. All other providers did, and other known infection causes have been evaluated based on real time data and excluded.”

I was reminded during a recent presentation by a venture capitalist that, when considering any new idea, the first questions should be, “who is bringing the idea, and are they a friend of foe?” If it’s a great idea coming from a serially successful, smart friend, then you definitely keep listening and assume an inviting posture.  Otherwise, you need to be far more cautious. That’s the framework I’d like to apply to the newly emerging technology of Indoor GPS.

Navigational GPS has generally made driving through unfamiliar areas a reliable process. In recent years, we’ve become relatively spoiled, in that our smartphones can tell us where we are, where we’re going, arrival time, and alert us dynamically to options that may be a few minutes faster based on real time traffic updates. In addition to supporting navigation to drivers, pedestrians are increasingly using GPS to find their way while walking, especially in cities. 

Beyond navigation, there are location-based services (LBS) supporting other activities, including giving us selection options in any application that take into account where we are. For example, the availability and wait time for taxis is now available from several services such as Uber. Like oxygen, we’re coming to the point where we only notice GPS when it’s gone.

So let’s fast forward.  We are now entering an era where a variety of technologies  are making it possible to do GPS indoors using ubiquitous devices such as smartphones with Bluetooth. They make it possible to extend navigation inside structures like buildings, and less obviously, to specific aisles, shelves, etc., within those buildings. In my HIMSS 2015 blog post, I described a scenario of finding the location of a specific type and brand of lettuce in the supermarket, and getting directions to within an inch of that lettuce. This technology, with its negligible transaction costs, is now a mainstream capability.

For consumers, exercisers, dieters, or other diverse groups, this functionality is being adapted to provide significant new insights beyond navigation. We are now collecting miles ran or walked, steps taken, stairs climbed. We can and are getting this information summarized for us, with no additional effort on our part, by the hour, day, week or month. Your step data can be collected by your smartphone. This data can readily be combined with other information, including heart rate and weight, in a minimally intrusive way. Increase the data by collecting diet information and there’s a lot of highly relevant, new health information available. So, for most of us, the technology would appear to be a purely friendly thing.

But it could be used against us. Suppose a business constructed a model where it could alert obese, sedentary people, known through their past location data and credit card usage to frequent fast food restaurants. These people could then be given specific “offers” that would be more attractive and relevant to them than diet restriction and increasing exercise. From my perspective, I would chalk-up this use of the technology as a foe, because it is tantamount to an invasion of privacy. Now, what does all this mean for health and healthcare?

For healthcare provider organizations, indoor GPS has lots of applications. An obvious one is wayfinding. When my daughter needed a leg X-ray and cast removal last month, both services were located a distance from the clinic where they were ordered, and the path from place-to-place was literally a maze. Lots of little, tight hallways, closed doors, no signs or confusing signs, and lots of other sources of confusion.  A smartphone app with indoor navigational GPS would be a friendly service, although unlikely to directly improve revenue or decrease cost for that provider organization.

This brings us back to the story opening this post. There seems to be at least one additional category needed beyond “Friend or Foe.” Should we routinely use continuous location monitoring and management as described in the MRSA story?

Many provider organizations have tagged individuals, including nurses, doctors, therapists, technicians, and others with devices that enable locating them with precise, real time and continuous tracking. By analyzing this information, it becomes possible to identify exactly when and where, for example, these folks wash their hands. Precise indoor GPS makes it possible to measure this behavior, and, after all, providers should wash their hands upon entering and leaving rooms where they interact with patients. So, it’s a good thing to monitor clinicians at all times. Right?

I propose we consider some additional word, a category, preferably starting with an “F” to describe a “Big Brother” technology that may be viewed by some as a necessity, but that is certainly intrusive.  Yet, if we’re capturing this data as a byproduct of operations, can we justify not reviewing it and using it, as described in the opening Bob story?  Whether or not Bob is being falsely accused, is this scenario fair to Bob and Bob's patients?

What do you think?




Dr. Joe,
I’m very pleased you have started blogging again. Your views and opinions have been sorely missed on this site.

About the topic at hand, I have become a huge proponent of modern technology in healthcare. But in many ways, I find the story you used as an example quite troubling. If a hospital deploys indoor tracking tech, on the surface, I have no problem with using it. However, there must be stringent policies in effect that control access to such data, how it can be used, and how long it is retained.

I can understand how knowing where a specific person or persons may be located in time of crisis would be helpful. And in your example, it’s somewhat understandable why a hospital might want to track down who or what caused an infection that has affected patients. But without strict policies with inflexible, severe penalties in place to prevent clandestine use of the data, I would be against deploying such technology.

To date, we are unable to prevent hackers from stealing huge troves of patient medical and personal information, and hospital staff are known to regularly sell for personal profit the medical records of the rich, famous, and infamous. With that in mind, I find implementing indoor tracking systems for hospital employees to be an unacceptable practice at this time.

Unfortunately, human nature being what it is these days, this really is “Big Brother” management in action. It is not simply invasive, it’s insulting. Using this technology in the current environment also shows not only a lack of professional trust, it holds the potential to undermine care team cohesion and spirit.

Keep us the great work!
Doc Benjamin

Doc Benjamin,

Thanks for your kind words.

I (and many others) share your perspective that this is a slippery slope. It's one thing to have surveillance cameras at banks and all-night convenience stores, only accessed by trusted parties after a crime.

It's wholly a different thing if we open and publicly published our bank balances, purchase histories, and when, where and how we showed up at these and other venues, including our homes.

The recent multi-million dollar fines awarded against Uber for not sharing ride data are just another dimension of the liability issues associated with the new transparency that's possible.

As I tried to address in the post, the cat is already out of the bag and the horse out of the barn in retail in the non-healthcare commerce space. And, per my last post, with consumer engagement and their rewards programs, we're already, largely with OPT-IN paradigms, collecting consumer data. See Timothy Morey's Consumer Data, Transparency and Trust article in last month's Harvard Business Review.

Thanks again for your comment. It's critical to discuss these issues and implications, especially as it relates to our field, Healthcare Informatics.


Hi Dr Joe. Agree, it is terrific to see you blogging again!
This is a fascinating topic and very thought provoking. I'm glad to see the word choice of "you most likely gave 4 patients MRSA". As a former practicing clinician and administrator, it is so important to have as many facts as possible before making indictments. Sometimes a clear picture is not so clear. If Bob pulls out a container of hand cleanser/anti-microbial from his scrub pocket with an explanation that he doesn't use the hospital product due to contact dermatitis, the dots may not completely connect to get the expected picture. the old saying about "looking like a duck, walking like a duck, and quacking is it a duck?" comes to mind. I do believe that objective data is a good thing, we just need enough to make the case be the compelling and truthful story. Again, thank you for posting a great piece.


Thanks for the kind words and insight.

I was taught decades ago that data analysis needs to be always done in a disciplined, three step dance:

1) Follow up on collected data with review, univariate, and co-occurence considerations. Today, that often includes a Pivot Table, Auto-Filter views, histograms, and a search for appropriate raw benchmarks.

2) Go out and see how the data was collected. All too often, the collection process produced misleading counts.


3) Take the data, in a collaborative, safe, internal process to those responsible for generating the data. "This is what we're seeing in the raw data. What do you think?"

This is essential before any considerations of "publishing" one's findings. In the majority of cases, as you suggested, the inference changes completely.

It's a common rookie mistake to get overly excited before getting to step 2.

Thanks again for your comment, Laura.


Interesting and provocative. The technology itself is morally neutral. The uses to which it is put is another matter. Or maybe it's more about how technology is put to use. MRSA infections are fact. I'd be hard pressed to argue that my right to privacy in my bathroom hand washing habits outweighs a patient's right to not contract MRSA from my unwashed hands -- if indeed the evidence clearly establishes that the indoor GPS could demonstrate that conclusively.

Also, think of the many uses to which indoor GPS tracking could be put. All the way from your simple wayfinding to real-time patient tracking to tracking individual vials of narcotics. So the cost to establish MRSA-handwashing tracking may be only the incremental cost above the base cost of a wayfinding or inventory control system.

Finally, looking at it from the opposite view: what is institutional liability for not implementing a solution to a known problem that has a known solution? If an indoor GPS could really prevent MRSA, what would a jury award to a patient who contracted MRSA in a hospital that failed to prevent the preventable?