21st Century hospitals - pressures for transformation
New service and business models are challenging the traditional role of a hospital – as a place where sick people are taken to get better. Instead, a growing body of evidence suggests that the key mission of future hospitals will be to help people to avoid falling ill, and to manage those that do in fundamentally different ways than at present. Such processes are principally driven by economic pressures and the promise of new technologies. However, patients are also playing a major role.
Patients more proactive
It has indeed been apparent for some time that patients are far less passive than they were in the past. In Britain, a study by the King’s Fund think-tank found patients wished to be far more involved in healthcare decisions. In addition, the study reported that patient satisfaction depended not just on medical outcomes, but also on being treated with dignity and respect.
Emerging technologies are seen as one way to enhance the patient experience, and several popular apps show how rapidly patients have moved to centre-stage. In the US, Heal, a smartphone app, lets patients search for physicians in a manner similar to Uber’s connecting passengers to drivers. Zocdoc, another tool for finding doctors, has added an artificial intelligence-powered Insurance Checker feature which lets patients select and verify insurance information as they are booking appointments. An app called Welloh goes beyond doctors to give users information about hospitals, pharmacies, care centres and other facilities. Clinical trials are also opening up to volunteers, thanks to an app called TrialReach, which helps patients find open clinical trials for specific medical conditions.
These new health access paradigms resonate strongly with younger patients. According to a report from Salesforce, over 70 percent want their physicians to adopt mobile health applications.
Apple integrating health apps
Evidence of the opportunities arising from enhanced patient participation comes from Apple, which plans to bring the current clutter of healthcare apps under one roof. Its new Health Records feature will allow users to see their records of allergies, immunizations, lab results, medications and other conditions in a single window and send notifications when any data is updated.
One of the most promising and best known tools in the emerging technology arsenal is computing giant IBM’s Watson, which deploys artificial intelligence (AI) to collect and interpret vast amounts of data from medical literature in order to advise on best treatment options. Scores of other tools provide personalized treatment plans for cancer patients using the genetic background of their tumours, accompanied by analysis from tens of thousands of other, similar cases.
These kinds of innovations count on assimilating and interpreting what has come to be known as Big Data. The sources for this data, whose volume continues to grow by leaps and bounds, are many. They include clinical studies, prescriptions, radiological images and a host of other healthcare information.
The Internet of Things
One new source of data is from the Internet of Things. Connected medical devices such as insulin pumps and pacemakers pick up signals and automatically transmit information to networked computers, which allow physicians (and patients) to perform real-time monitoring.
An array of wearable devices to track vital signs are another fast-growing source of medical data. On an individual basis, this may not amount to much. However, when the data is provided by millions of users, its size becomes staggering, as does its potential for providing insights.
Such a burgeoning mass of data is being generated asynchronously, processed and stored by different machines on multiple platforms. Making it usable is hardly simple.
One promising answer to such a challenge lies in cloud computing technology, which has dramatically reduced the cost of data storage, as well as the time required to process and transfer the data to multiple users at different locations. For patients needing to visit a lot of specialists, the accessibility of their data from a variety of locations can be indispensable.
The Electronic Health Record
One of cloud computing’s biggest areas of impact may be the electronic health record (EHR), one of whose goals was in fact to address the above challenge – patient data access in real time by different specialists.
The EHR has generally failed to meet expectations (and over-expectations). In both Europe and the US, the EHR’s key technical/operational limitation was that clinical and financial data could not be easily shared and exchanged among providers – as many had assumed or otherwise hoped for. In the US, EHRs have generally also failed to meet levels of reporting that support the ‘meaningful use’ requirements of pay-for-performance programmes.
Cloud computing seems likely to give a new lease of life to the EHR. Server-based EHRs always run the risk of system failure, which would prevent access to critical patient data until the server has been restored. Such a scenario does not concern cloud-based EHRs. In addition, cloud services are encrypted and provide security. Cloud-based EHRs also reduce entry barriers to adoption by transferring responsibility for confidential patient information to specialized vendors.
Design and hospital re-purposing
The impact of such developments are reaching into the very design of a hospital. Christopher Shaw, Chair of a professional organization called Architects for Health and founder of the design firm Medical Architecture, believes there is a growing mismatch between the physical infrastructure of a hospital and the nature of activities expected to be required over the coming decades.
One key question here is the future of hospital buildings – whether to renovate and incrementally redesign structures or start afresh. Indeed, even as popular imagination associates future hospitals with robotic doctors, another equally beguiling scenario consists of individualized medicine, extending to some forms of surgery, carried out at home.
The reality may lie in between, at least in the foreseeable future. One of the most likely scenarios might be a hub-and-spoke hospital model. Its inside tier would consist of academic medical centres serving larger populations and focused on acute care. The middle tier would be an intermediate-care hospital, located in smaller cities or larger towns and providing longer-term rehabilitation and nursing support. The outer tier would be comprised of polyclinics for outpatient diagnostics and elective care, referred from primary care physicians. At the periphery would be the patient’s home, with telemedicine treatment, and possibly some form of tele-surgery assisted by paramedical professionals on the scene. Some of the latter may well be robots.
After many false starts, telehealth technology is now on the edge of take-off – helping allocate care to patients more efficiently, by eliminating the need to visit hospitals, when they do not have a need to access concentrated multi-disciplinary expertise.
Telehealth is also seen as a means to bring patients back more quickly to their homes. Indeed, there is a considerable body of evidence which suggests that the sooner patients begin recovery at home, the more quickly they heal.
Telehealth is not only being pushed by technology but also pulled by economics. In the US, for example, healthcare providers of diabetic patient care have to contend with value-based measures. As a result, they are becoming increasingly dependent on real-time data from remote glucose monitors. Telehealth allows patients to be more engaged, and participate with physicians in ensuring better outcomes, by adhering to insulin or other medications.
Emerging models - examples
The challenge facing the emerging healthcare model lies in the best way to integrate resources, delivery and support mechanisms, and the need to avoid duplication. However, there are encouraging signs from several parts of the world.
In the US, Westchester Medical Center Health Network (WMC Health), is an example of the emerging hub-and-spoke hospital model. The core of the system consists of a 1,500-bed facility headquartered in Valhalla, New York, which is the only facility for complex interventions and procedures. Buttressing this are six (intermediate) hospitals, as well as several polyclinics and medical campuses. The system covers a population of more than 3 million people spread over 15,000 square kilometres.
In Europe, there are several efforts to redefine hospital design. In a variation of hub and spoke, Guy’s Hospital at London has developed its cancer centre as a stack of ‘villages’, one atop another, with each providing a different service (radiotherapy, chemotherapy, etc.).
Certain hospitals have sought to move in the opposite direction, bringing a full range of services to patients in one room or area. In Veldhoven, the Netherlands, a new Woman-Mother-Child Center at Maxima Hospital provides prenatal, delivery, postnatal and breastfeeding support services from one room.
UMC+ in Maastricht, NL
Some of the most radical efforts to address the redefinition of the hospital are being explored in the Netherlands, at Medical University Centre+ (UMC+) in Maastricht.
In late 2009, the departments of Dermatology and Orthopedics at UMC+ started out on separate tracks of what is called ‘design thinking’. Each department independently developed and implemented new care and financing systems, closely adapted to what they saw as the real needs of their patients, and combining specialities, which had been traditionally separated.
The key mission at UMC+ is to avoid pushing strategy down individual departments, which have highly specific patient groups, processes and technologies, and instead build strategy bottom up, involving inputs from across the staffing chain.
Nevertheless, the aim of design thinking is to also generate organizational change. Over time, several other departments began applying the methodologies pioneered by Dermatology and Orthopedics, creating a new hospital healthcare model.
Over time, the UMC+ model is transforming healthcare focused on rehabilitation, to preventive public health and development. The shift has also changed the role of the Board. Directors no longer set out strategies, but make communication possible between different departments. The Board aims to ensure that different departments do not seek to reinvent the wheel, and instead continuously develop and implement internal best practices.
The challenge of demographics
Nevertheless, many challenges still lie ahead. While Internet- and smartphone-friendly millennials are clearly going to benefit from new hospital care models, the bulk of hospital and healthcare needs for the next decade or two lie in the elderly. According to a Partners HealthCare study in 2016, few seniors obtain information or accomplish healthcare-related tasks online. Only 16 percent of seniors said they used the Internet to obtain health information, while just 7 percent contacted physicians online.