The hospital of the future

ACP Hospitalist interviewed experts in technology development, health care design and hospital administration to learn about upcoming changes in hospital operations and design.


The robots are coming! The machines are talking to each other! Your movements are being tracked and recorded!

No, these aren't taglines from science-fiction films. They are reports from the cutting edge of hospital technology, and indications of what a typical hospital might look like in the not-too-distant future.

Illustration by Dave Cutler
Illustration by Dave Cutler.

ACP Hospitalist recently interviewed experts in technology development and health care design, as well as administrators at hospitals so new they are not yet open, to learn about likely changes in hospital operations and design that have the potential to affect hospitalist practice.

The news was mostly good, even for hospitalists who don't think of themselves as particularly tech-savvy. “When people see a new technology being deployed, they automatically think, ‘Oh, great, I've got more work to do,’” said David Sharbaugh, president of SmartRoom, a technology company owned by the University of Pittsburgh Medical Center (UPMC) and jointly funded by IBM. “We're just the opposite of that. We're trying to subtract work and effort and make life simple and safe for the people out on the front lines.”

The room

Like Mr. Sharbaugh, many hospital innovators are focusing on the patient room. His product, SmartRoom, is based on location awareness—in other words, computer systems that are able to recognize a person's identity and location. This is currently accomplished by all hospital staff wearing an identification tag that computer sensors can read, although future systems could use more advanced technology, such as facial recognition.

The impetus for development of SmartRoom was a case in which a nurse used a latex tourniquet to put an IV into a patient, despite notes in the patient's electronic medical record about her latex allergy. “The patient was very angry because she had been to our hospital many times before and she wondered, ‘Why didn't we know that she had a latex allergy?’ The fact is that we did know. The computers knew and the cables knew and all the hard drives knew, but the person who needed the information didn't have it,” said Mr. Sharbaugh.

If the patient had been staying in a SmartRoom (which the company has installed at UPMC and is discussing with other hospitals), a screen in her room would have turned on when the nurse entered. The screen would have introduced the nurse to the patient and alerted the nurse to the latex allergy and any other information likely to be relevant to the interaction.

The screen can also provide information about vital signs, medications and lab results—pulled directly from the lab's computers. “The first time that I used it, we caught a life-threatening critical lab, which was potassium less than 2.5 mEq/L, that had yet to make it through the alert system,” said Andrew Watson, MD, a UPMC surgeon.

Since the information on the screen is visible to both clinicians and patients, the technology also has the potential to involve patients more in their own care. “When I walk into the room now, patients typically say, ‘I want to see what's going on. Can you please review these things with me, or review the numbers with me?’” said Dr. Watson.

Hospitalists can generally expect future technology to involve patients, and their families, more closely in the provision of care, predicted D. Kirk Hamilton, a hospital design expert and associate professor of architecture at Texas A&M University in College Station. For example, screens in patient rooms at many hospitals are already being used to provide patient education (such as on-demand videos), and newly constructed rooms are allowing much more space for visitors.

“In today's new designs, there's almost always a zone of the room that's considered the family zone, and it generally has some sort of sleeping accommodations, so that a family member can actually spend the night there,” said Mr. Hamilton. “As there is a shortage of nurses and others, it may be that the family begins to perform more and more in terms of cooperative care or helping the staff with taking care of the patient.”

Whether they are providing care or just company, family members who are spending time in the hospital will require more connectivity with the outside world. Patients, too, often want Internet access during their hospital stays.

An email account where patients can receive messages and pictures is part of the current UPMC system, but James Lewis, MD, senior technology analyst for Kaiser Permanente, expects hospitals to offer even greater connectivity in the future. “When you're in the hospital, you're not usually in a coma,” he said. “What about real-time connection to the outside world? It's beneficial that they can still have contact with their family. It's beneficial potentially, even though they need rest, if they are in touch with their business.”

The connection could also eventually be expanded to video conferencing, either with loved ones or other physicians, whether they are distant specialists or the patient's own primary care physician, the experts said.

Hotel hospitals

Outside connectivity is part of a general trend to make hospital rooms more like hotel rooms. Such redesign has been one focus of efforts at the Garfield Innovation Center in San Leandro, Calif., a facility where Kaiser Permanente tests out new technologies before implementing them in its hospitals.

“We challenged ourselves to design a patient room that was more appealing to patients,” said Faye Sahai, executive director of innovation and advanced technology at Kaiser Permanente. “It doesn't feel so cold—more welcoming and comfortable for them” with the inclusion of environmentally sensitive design and different lighting, she said.

One simple way to improve hospital lighting is to allow natural light, according to David Tam, MD, a pediatric neurologist and chief administrative officer who is overseeing construction of Palomar Medical Center West, a Southern California hospital scheduled to open next summer.

“Patients exposed to natural light actually heal better and faster,” he said. “It's incredibly important for staff—employees as well as hospitalists—who are in the hospital for 24 hours to have an awareness of the circadian rhythm of the day.”

At the new Palomar hospital, every operating room and the entire basement—where the pharmacy, pathology and lab will reside—have a source of natural light. “It's documented that staff who are exposed to natural light and know when it's daytime outside or nighttime actually have fewer medical errors than those who don't,” said Dr. Tam. The improvement in lighting was facilitated by the inclusion of a museum architect in the hospital's design process. That expert also helped develop signage for the new facility to make it easier for patients and families to navigate.

The rooms at Palomar will have some other unusual features designed to help clinicians do their jobs. Traditional hospital design has included alternating layouts for patient rooms, so that plumbing for two rooms can be shared in a single wall.

“Our hospitalists as well as our nursing staff identified evidence-based research that said that causes more medical errors. In times of emergency and critical situations, it makes sense to have rooms exactly identical,” said Dr. Tam. “So in our hospital, the bed is always on the left when you walk in and the sink is always on the right. When you look at the bed, all of the oxygen outlets as well as the vacuum outlets and everything are all in the same place in every single room.”

The new design, known as samehanded rooms, is expected not only to provide benefit in emergency situations, but also to simplify routine practice, “everything from putting in an IV to doing a physical exam,” said Dr. Tam.

The rooms will also be alike in the level of acuity they can handle. “Our rooms are all built to the same standards as an ICU room,” said Dr. Tam. “When a patient gets sicker and goes from a med/surg to an ICU kind of patient, the room becomes ICU.” In addition to reducing stress on patients and families, this change should be appealing to hospitalists, as it will save them having to track their patients' moves in and out of the ICU, telemetry or other areas, Dr. Tam said.

The new setup will potentially require more travel on the part of ICU nurses, who may have to go to their patients instead of finding them all necessarily in the same spot. The design of the hospital holds other changes for nurses, too, including the elimination of nursing stations. “Instead of a nursing station, we have a technological solution where the doctor can call the nurse directly,” said Dr. Tam.

Better communication

Improving the channels of communication is a major focus of hospital innovation, the experts said. “We know that communication is probably the single worst problem for the clinical team,” said Mr. Hamilton.

Location awareness systems, which track staff through the hospital, could help to improve communication. “It will simply be the easiest possible way to find your nurse. It will be an instant way for communication between a central clerk and any of the staff on a unit, without having to use overhead paging, which disturbs everybody and causes breaks in everybody's sleep cycles,” said Mr. Hamilton.

The systems could help find equipment as well as clinicians. “You could look at a screen and see where all the wheelchairs in the hospital are, or you could see where all the nurses' aides in the hospital are, or you could see where the anesthesiologist is, or where a highly expensive infusion pump is,” said Dr. Watson.

“Unified communication streamlines the hunting and gathering that happens in hospitals,” said Ms. Sahai. Another change to communication that the innovators hope will reduce hunting and gathering is called push technology. “Stuff that you really need is sent to you without you having to go and search for it,” explained Dr. Lewis.

That could include lab results or notifications that a medication is ready, for example. In current practice, “You go to get a medication. It's not there yet,” described Ms. Sahai. “If you got a text message, ‘Your medication for Miss Thomas is there,’ you go and you've now saved two trips when you were going just to check.”

It would be even more convenient if a robot brought the medication on its own. Forth Valley, a hospital recently opened in Scotland, features robot delivery of supplies as a major component of its design. In an underground network of corridors, robots move linen, waste and patient meals.

“A nurse on the ward will, using a handheld PDA, call up the patient meals. The host PC receives that request and a robot is dispatched to complete the task. The robot then travels along the underground corridors till it reaches the kitchen. It picks up the cart by itself and takes that cart to the particular ward that it's meant to go to,” said Ian Mullen, chairman of the hospital.

At Forth Valley Royal Hospital in Scotland robots move linen waste and patient meals in an underground network of corridors Photo courtesy of Forth Valley Royal Hospital
At Forth Valley Royal Hospital in Scotland, robots move linen, waste and patient meals in an underground network of corridors. Photo courtesy of Forth Valley Royal Hospital.

The Scottish robots are expected to not only save clinician time but also reduce crowding and potential for contamination in hallways, since they travel in tunnels not used by patients, families or clinicians, Mr. Mullen said.

The Garfield Center is also working with robots, according to Ms. Sahai. The use of robots in hospital pharmacies has already become fairly commonplace, but Kaiser Permanente has implemented courier robots that roam the same halls as patients and carry supplies. “It has facilities' layouts programmed in and automatic sensors so it will not run into people, and it's actually polite. It says, ‘Excuse me,’” she said.

Interoperability

Potentially even more useful than talking robots would be communication between the simpler machines that are already in the hospital, another advance that researchers are trying to put into practice. “It can be a biomedical device that measures something and then has to communicate that information to an electronic medical system. Or you might have two different electronic systems that are used to keep track of certain things within the hospital. Those things are ultimately getting more and more to the point where they have to be able to seamlessly connect with one another,” said Dr. Lewis.

For example, a blood pressure cuff that automatically transmits its readings to an electronic medical record could save clinician time and eliminate transcription errors. Communication between systems could also make checklists easier to use. “For example, if the question [on a pre-surgery checklist] is, ‘Is there blood ready in the blood bank?’ you could click on that question and a window would open up with the lab results from the blood bank, showing, ‘Yes, there's two units of blood available,’” Dr. Lewis said.

If devices communicate better, it might also be possible to have fewer of them. “Our nurses have a toolbelt that's around their waists that has their cellphones, some even still pagers, bar coding devices, pens, papers, tablets, walkie-talkies,” said Ms. Sahai. “How can we unify that to one device that effectively routes alarms, notifications, critical communications in a timely manner, with a usable interface, so it's not so complicated?”

Currently, the best answer to her question is middleware, computer systems that translate and route information between devices, according to Dr. Lewis. But researchers hope to move device-to-device communication to the next level. “The holy grail is true plug-and-play interoperability where every device that a manufacturer makes has to meet certain standards,” he said.

The biggest obstacles in that quest are business-related, because manufacturers profit from their proprietary systems. “Many organizations, including Kaiser, are involved in standards development and harmonization—organizations whose sole purpose is to try to simplify and ensure interoperability,” said Dr. Lewis.

Barriers

There are other issues that need to be resolved before the hospital of the future is fully operational, the experts noted. Even the SmartRoom, which is in use at UPMC now, has some detractors. “Not every single one of them (in the physician group) wants to get their data at the bedside,” said Mr. Sharbaugh.

Some clinicians are also leery of hospital-wide location awareness systems. “There's some resistance on the part of staff in some places, where they think this is Big Brother watching over them and can be used against them. There certainly has to be some orientation and protection for the staff from uses that are inappropriate,” said Mr. Hamilton.

Determining the appropriate use of robots will also require time and experimentation, he said. The value of robotic couriers typically depends on the cost of the workers they replace. “These are expensive systems. They do have occasional maintenance breakdowns. But whenever they are installed in places where the labor cost is really high, they can pay off,” Mr. Hamilton said.

Cost is generally a hurdle to many of these innovations, especially in the current economic environment. “You have to prove earlier on the impact to cost—prove that it is increasing quality, safety, outcomes very early on for [hospital administrators] to move forward. It is more challenging,” said Ms. Sahai.

Using evidence to determine the best course of action is as big a theme in design as it is medicine, and more research is needed to determine the best possible setups, according to Mr. Hamilton. “For example, I would like to believe that if clinicians were doing their hand hygiene effectively and could at the very same time be looking at the patient, there's a higher probability that they would leave their hands under the water the appropriate length of time,” he said.

Another solution to the cost crunch is to find other areas to cut expenses to pay for the innovations. At Palomar Medical Center West, green design will reduce utility costs and the hospital administration served as its own general contractor. “Yes, this is a pretty expensive hospital, but the innovations are not just in the actual design, but in the construction,” said Dr. Tam.

The design and construction process included significant input from the physicians who will work in the hospital, which Dr. Tam thinks will be an increasing trend. “That's going to be a driver, a motivator for physicians to want to work at your facility. You've got to have them as part of the team that designs where they work,” he said. “We said to physicians, ‘Go to your conferences and find out the latest stuff, because you have a shot at telling us what you want five to 10 years from now.’”

Dr. Tam predicts that they'll be pleased with the final results when they are unveiled next summer. “I remember rounding in patient rooms and the place was so small you'd bang your head on the TV, and running around trying to find a terminal so I could check labs,” he said. “I think patients and physicians will really appreciate some of the stuff we're doing.”