The New Age of Hi-Tech Hospitals
Information Technology and digitally enabled medicine may be converging onto a single system, but are architects prepared to take the lead with their health-care clients.
The best new digitally enabled American hospital of the next five years may be in Qatar. This tiny Middle Eastern state has brought together American architects Ellerbe Becket and Pelli Clarke Pelli to design the technologically advanced Sidra Medical and Research Center, part of the ambitious Education City project in Qatar's capital of Doha.
If built as planned, Sidra would epitomize a fairly progressive model of acute-care hospital design, where architects and their clients deploy technology in a variety of modes: in the realm of patient care; for enabling international collaboration and education in the medical field; to operate building systems; and to design the building itself. Perhaps most explicitly, technology could be used as a way to explain the hospital and its spaces to visitors. But what all of these disparate applications may ultimately share is a single digital conduit-or backbone-that collapses the information technology (IT) supporting the processes of running a hospital onto a piece of fiber-optic cable.
"Before, each system had its own cabling infrastructure, while now that's no longer the case," says Joe Leger, a Seattle-based principal with EDI, a group of information-technology consultants based in Atlanta who specialize in health-care technology. "When we ask for large rooms for IT, architects cringe, but we're actually saving space because traditionally we would have been asking for individual rooms for each system." Leger is consulting with Ellerbe and Pelli on the nearly 400-patient-bed, 1.7-million-square-foot Sidra project. The hospital-Sidra is the name of an indigenous tree in Qatar-will be operationally connected to the Weill Cornell Medical Center in New York City.
Nowhere has convergence caught on more than in the operating room (OR) suites, where the past five years have seen an explosion in the use of flat-screen monitors, interventional radiology equipment, and videoconferencing capabilities that have brought such heretofore invisible support equipment, like IT racks and cabling wireways, into a realm previously considered sacrosanct for reasons of hygiene.
Contrary to this development, however, the emergence of the IT consultant as a major player at the health-care design table continues slowly, with many consultants still lamenting that by the time architects include them in the process, it's often too late. Furthermore, the health-care industry, and its architects, increasingly grapple with a variety of digital-infrastructure issues, such as myriad cable options and space planning, that have yet to be codified. But industry players see change on the horizon.
All systems go
The sheer number of digital systems that go into a hospital has encouraged clients to embrace convergence. On the medical side, these systems can include both informational and clinical kinds, such as Electronic Medical Records (EMR), Picture Archival and Communications Systems (PACS), and radio frequency identification tagging (RFID). Systems such as nurse call, code blue, fire alarm, and telemetry and patient monitoring (vitals) are placed on separate networks, since they are critical systems. Communications systems, such as voice-over Internet protocol (VOIP), video- and teleconferencing, and overhead paging, are also typically separate. Security, including infant abduction systems, are yet another separate item. The building systems side, typically the province of the mechanical engineer and a building-management system (BMS), often consists of monitoring the mechanical ventilation systems, indoor air quality, and humidity, as well as central plant equipment operating status. In some cases, the BMS may monitor lighting systems and energy use, though this is less common.
Hospitals have pushed for medical systems to go wireless, which conceivably allows medical staff, particularly nurses, to stay mobile and yet connected. For example, with a VOIP system, which routes telephone calls across a network-as opposed to a conventional phone system-a hospital can direct a call for a nurse to one of several locations: an office phone, pager, cell phone, overhead paging speaker, or even the nurse call device at a patient's bedside. This connectivity depends on a distributed antenna system (DAS) throughout the hospital; the antennae look like smoke detectors, but they are basically wireless on-ramps to the hospital's network. What makes this transfer between communication device, antenna, and network even possible is so-called "middleware," a software solution that translates the voice data between these various digital components. Mario Sanchez, a technology consultant with the Los Angeles office of RTKL Architects, refers to this concept as the "call-escalation procedure." Once a call is converted to data, moving it around the network simply depends on the preference of the hospital. "Facilities are being very slow at adopting this because it's a huge capital investment," Sanchez says, noting that many hospital projects occur on existing campuses where design teams face established standards for IT infrastructure.
Regardless of the potential for convergence, and given the sweeping nature of the Health Information Patient Privacy Act (HIPPA) passed in 1996, directing large amounts of sensitive data around digital networks has concerned many hospitals. This becomes more critical when a hospital adopts EMR systems, where a patient's entire medical history may be moving throughout a statewide medical records system, such as will be the case in Wisconsin. Mark Valenti, the president and C.E.O. of Pittsburgh-based technology consultants The Sextant Group, says firewalls are effective, but there can still be considerable security risk. "It's less expensive to build a couple of networks than to think about a converged environment, once you start to consider the risks," Valenti says. This is mainly true because most digital devices are fed with copper wire, since fiber optics are expensive and are used mainly for the backbone of the system. Copper wire, Valenti says, is easy to strip of data, but fiber-optic cables are secure and, since they hold so much data, would make systems convergence a snap. However, he says it could be 10 to 20 years before fiber optics are cheap enough to replace copper.
Converging bricks and mortar
Convergence translates to health-care architecture mostly through the centralization of these systems in massive new data centers, as well as the proliferation of smaller closets to handle wireless devices or critical components that cannot be housed with other systems. Consider that instead of three antennae in the corridor ceiling for different systems, one antenna feeds back to an IT closet where each system's control unit would be mounted in an equipment rack. With each additional system, more rack space is needed, and IT closets get larger. This situation, as well as how all of these IT considerations affect the operational procedures of the hospital, explains why consultants like RTKL's Sanchez argue for their early involvement in design. The tendency of architects in planning the building to use out-dated grossing factors-standardized area-allocation percentages-which affect square footage for IT space, only exacerbates the problem.
For example, take the PACS system, which is basically a digital X-ray, or could be something like magnetic resonance imaging (MRI) results. Doctors and radiologists use these images to diagnose a patient. A doctor may want to review that information at the patient's bedside, in an OR, or on a golf course, so the IT system must accommodate compression formats that support moving this data between everything from large-screen monitors to handheld personal digital assistants (PDAs). If the IT consultant can't establish these hospital operational needs early on, adding equipment racks at the end of the construction document phase may prove impossible. This is the sort of "planning" that leads to IT rooms in converted janitor's closets.
If you ask many IT consultants whether most architects understand what Crispino is saying, you're likely to hear a resounding no. But that is changing as more health-care clients have recognized how poor decisions about technology infrastructure can haunt their buildings for years to come. By 2009, it's expected that a new version of the National Fire Protection Agency's Standard for Health Care Facilities (NFPA 99) will codify things such as IT room sizes, basically forcing the issue on architects.
Operating rooms under the knife
The ORs in a new addition at New York City's Memorial Sloan-Kettering Cancer Center opened in May 2006. Designed by architects Perkins Eastman and KMD, with New York IT consultants Shen Milsom & Wilke (SMW), the technology installed in the 21 ORs represents an advanced model of digitally enabled health care. Aside from a PACS system, SMW designed a Digital Video Archival and Communication System (DVACS) that integrates digital video editing, indexing, digital video transport, patient monitoring, audiovisual systems, and various medical systems into a single, time-stamped digital file that could be searched based on spoken word, time parameters, or even something like heart-rate information.
For example, a doctor could review a procedure to pinpoint each time a patient's heart rate exceeded a certain level. Doug Santo, a consultant with SMW, helped develop each OR's Wall of Knowledge, which basically amounts to flat-screen televisions programmed to display things like radiology images, live video of the procedure, endoscopic images, or patient vitals. "In order to collect five physiological monitor feeds and combine them into one digital model is fairly complex," Santo says, adding that expensive software does most of the work.
The integrated systems in the ORs at Sloan-Kettering benefited a great deal from a client who knew how to coordinate the needs of both the surgical side and the facility IT side, says Doug Gordon, AIA, with KMD's Portland, Oregon, office. "In my experience, IT has definitely come around to become a more sophisticated part of the hospital's infrastructure, for surgeons and facilities managers," Gordon says.
At Sloan-Kettering, SMW installed a video-only IP network, to keep the huge streams of data from competing with things like e-mail on the regular network. Although this enormous video archive of thoroughly documented procedures opens the hospital to potential liability issues, it is a boon to medical education and to minimizing the need for invasive procedures. This last benefit is significant, as a doctor can now take a biopsy before a procedure and get digital results back quickly enough from a pathology lab that a diagnosis can be made in the OR. In some cases, it can eliminate the need to bring the patient back to the OR and under anesthesia again-which is always a risk-following a later diagnosis. The technology has enabled even further compartmentalizing of responsibilities, as SMW's Santo says some hospitals have electronically transferred radiology images to diagnostic services in India and Australia, to save both time and money. "The technology is just there to help the surgeons do their jobs better," he says.
Diagnosing the building
If anything has held up the convergence of these myriad electronic systems, it has been that medical-equipment and building-products industries have remained apprehensive about standardizing technology. Every nurse call system on the market uses proprietary technology. Building-management systems, which have become even more comprehensive in the past five years, also suffer this fate. What that means is that a health-care client must live with a specific system for years, if not decades, since changing would require a costly wholesale replacement.
A huge motivating factor for digital convergence is the developing standard 802.11-2007 of the Institute of Electrical and Electronic Engineers (IEEE). Without adding yet more acronyms to this article and further confusing the reader, this standard basically governs wireless networks in buildings, establishing protocols for bandwidth, capacity, and speed. As an example, EDI's Leger points to telemetry, which is a wireless system that allows hospitals to track a patient's vitals no matter where they are in the building. Currently, telemetry would be on its own network, but Leger says several manufacturers are working to operate systems over the 802.11 standard. As more types of technologies converge onto the 802.11 standard, fewer wires will be needed in cable trays. However, Leger is quick to admit wired networks won't go away, since they have unparalleled reliability. Building-management systems, provided by industry giants like Honeywell, Johnson Controls, and Siemens, among others, offer much potential for streamlining hospital operations. Devices like RFID tags, thermostats, chiller alarms, and light sensors could all communicate across a single network, which would allow other devices to be added in the future to create a digital mesh across the facility. IEEE's standard 802.15, commonly referred to as "ZigBee," governs so-called mesh networks. ZigBee is a data protocol for a low-power, low-bandwidth network, and it is the standard the industry will eventually adopt. A mesh network, as opposed to a daisy-chain approach, eliminates widespread failure because devices are connected to each other in multiple ways. A thermostat would connect to thermostats in each adjoining room, or could potentially connect to something like a light fixture ballast. Each point along that mesh is just another IP address in the network. RTKL's Sanchez considers this integration, or what we could call a "smart building," like an insurance policy against the future. "We know there's going to be more technology coming down the line," he says. "The most consolidation you can do at the beginning, the better you'll be positioned when it arrives." Cheap energy often prevents the implementation of such building-management systems. The Sextant Group's Valenti sees this firsthand, as he helped develop the Intelligent Buildings Roadmap for the Continental Automated Buildings Association. The Roadmap, finished in April 2007, is essentially a marketing push for the adoption of comprehensive systems in buildings to combine electrical, mechanical, security, communications, data, and just about anything else currently residing on a digital network. Valenti says there is little incentive for a facility manager to implement what could be a costly system, when energy rates remain historically low. "An intelligent building would have a piece of software programmed to automate all of this," he says. Valenti imagines that a client could tie room scheduling to the mechanical system, where a vacant conference room could shut its cooling off when not in use. That may sound like peanuts, but in a 500,000-square-foot hospital, the savings add up quickly.
That's the sort of thinking that motivates the design team on the Sidra project in Doha, which is being designed as a building information model (BIM) to achieve a seamless integration from the beginning. Travis Leissner, AIA, with Ellerbe's Minneapolis office, says visitors will get a taste of the digital convergence of the hospital's systems from the moment they walk in the door. Large, wall-size LCD screens in the atrium lobbies will direct patients to their appropriate hospital-adult, women's, or children's-based on the projection of related imagery. It's a bold, digital effort at wayfinding, often a sore spot with hospital patients. Summarizing the approach to the elegant campus, which begins construction this fall for a 2010 completion, Leissner says, "The concept for the hospital was to be both high-tech and high-touch, so patients have sophisticated technology in an inviting, healing environment." Once Sidra opens and the digital systems go online, patients may find they require more than just nursing care-perhaps also some bedside IT support to assist with e-mail.