Hospitals without walls: the future of digital healthcare

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St Mary’s hospital was slated for a £1bn redevelopment before the pandemic struck, with work due to start in 2027. The main emergency and specialist hospital serving north-west London will still get its upgrade, but it might look quite different now. “Covid-19 has dramatically changed things,” says James Kinross, a surgeon who works at St Mary’s and sits on its redevelopment planning committee.

Before the pandemic, Kinross says, the committee’s goal was to improve the efficiency of existing care pathways; now it’s to rethink those pathways entirely. St Mary’s is a test case, but the shape of healthcare is being reconsidered everywhere and that has major implications for the way hospitals will look in future.

George Mann, an architect and pioneer of evidence-based hospital design at Texas A&M University in College Station, compares the coming transformation to that of commercial airports in the past. The first airports resembled train stations, because it took people time to realise that transport would never be the same again. “I don’t think we totally understand that we’re in the middle of a paradigm shift,” he says.

That might sound like hyperbole, given the eternally cash-strapped state of many healthcare systems and the anticipated economic downturn due to Covid-19, but think of the changes the pandemic has already forced through. The Chinese built a hospital in 10 days, while in many countries medical consultations shifted online. Meanwhile, existing hospitals – even and perhaps especially in the wealthy global north – buckled under the sudden, immense strain.

Xiaotangshan hospital in Beijing, which was built in just 10 days.
Xiaotangshan hospital in Beijing, which was built in just 10 days. Future medical installations will have to be highly adaptable and modular. Photograph: Xinhua/REX/Shutterstock

Pictures flashed around the world of Covid-19 patients sitting in their cars outside a hospital in Naples, breathing oxygen from tanks. Non-Covid patients have seen their potentially life-saving treatments postponed indefinitely, while hospitals have themselves seeded Covid clusters.

None of this is surprising, says hospital architect Thomas Schinko of Vasconi Architectes in Paris, because the world’s richest countries have all but eliminated the concept of contagion from their hospitals, infectious diseases no longer being the biggest killer there. “We’ve lost that reflex of protecting personnel from patients or patients from other patients,” says Schinko. Result? “Our health systems are completely unadapted to this kind of disease.”

The pandemic has accelerated some trends, such as the one to a “hospital without walls” – the hospital conceived as a digitally connected community rather than a circumscribed physical space. The twin pillars of digital health are electronic health records (EHRs), which allow patient information to be shared across health systems, and telehealth, which allows patients and physicians to communicate at distance.

Many countries had been moving towards both since the 1990s, but at different speeds and with different degrees of success. In the UK, for example, most GP surgeries now use EHRs, but hospitals are further behind. There are genuine obstacles to embracing digital health provision, says Saira Ghafur, a respiratory physician and the lead for digital health policy at Imperial College London’s Institute of Global Health Innovation. These obstacles include inequality of access to IT and concerns about cybersecurity.

The risk of cybersecurity breaches was dramatically highlighted in 2017, with the WannaCry hack of the NHS, while in the last year US hospitals have seen a wave of them. Such breaches can happen in any tech-enabled industry or domain, but the case in September of a patient who died during a cyber-attack on a German hospital served as a reminder that the stakes when it comes to healthcare are the highest.

Nevertheless, Ghafur says, since Covid, during which we have experienced the benefits of receiving care in the comfort of our own homes, such obstacles seem surmountable. “Almost overnight we’ve gone from face-to-face consultations to the vast majority being what we’d call digital-first – by phone, text, video call or online,” she says. “That has fundamentally changed the way that we deliver care.”

A medic administers oxygen to a Covid-19 patient in their car at the Domenico Cotugno hospital in Naples, early November last year, as the facility had run out of space.
A medic administers oxygen to a Covid-19 patient in their car at the Domenico Cotugno hospital in Naples, early November last year, as the facility had run out of space. Photograph: Fabio Sasso/REX/Shutterstock

And she thinks those changes are here to stay. The results of a survey of nearly 10,000 patients in London, which her group will publish soon, suggest that in general they want more, not less, digital healthcare. Though it certainly doesn’t suit everyone, in future people will have more choice in how they access healthcare – being able to mix and match channels.

With the move to digital, Schinko says, we’ll see medicine becoming more preventive, as well as more personalised and precise. Patients with asthma and diabetes are already used to monitoring their peak flow and blood sugar (retrospectively) through dedicated apps, for example. And the adoption of a more “salutogenic” approach, which emphasises health rather than disease, is visible in China and the US, which have invested heavily in digitisation.

In China, for example, the care pipeline for infectious disease starts at the airport, with routine temperature checks (even outside a pandemic), while the Children’s Hospital of Philadelphia, considered one of the most technologically advanced in the US, offers services through its web portal and in 2019 launched a pilot telehealth programme in schools. The goal, in each case, is to prioritise surveillance and early intervention.

This is the hospital without walls – the hospital that is everywhere, embedded in our lives. And since some medicine will always require patients and medical personnel to meet, it will inevitably shape the places where that happens, too. Kinross says that before the pandemic, the St Mary’s planning committee was considering shifting resources from inpatients to outpatients. Now they’re thinking more boldly. “Maybe we can just do away with some aspects of outpatients and deliver all of this care outside the hospital,” he says. “Maybe we can leverage digital in a radical new way.”

Kinross envisages primary- care physicians or GPs taking on more responsibility (aided by decision-support technology), secondary care or specialist doctors spending more time in the community and an expansion of social care. Hospitals as physical entities will become specialist hubs, he says, with each specialism concentrated at one or a few hubs within a region, rather than replicated across many generalist hospitals.

Such a health system might have been better equipped to manage this pandemic, and reduce its impact, but it’s unlikely to have prevented it. Since future pandemics are inevitable, and since we don’t know when or where they will emerge, how should healthcare systems prepare? “What we can’t afford to have is lots of empty beds in hospitals doing nothing, waiting for a once-in-a-century surge,” says Kinross.

Hospitals plan for all kinds of mass casualty events. But as John Mazziotta, who runs the University of California, Los Angeles (UCLA) healthcare system, said in a recent podcast, planning is easier when these events involve a sudden influx of patients whose numbers then taper off. “This [pandemic] is a mass casualty event that evolves in slow motion in the other direction and keeps getting worse until it peaks and it was harder to plan for,” he said.

Several solutions have been proposed. All patient rooms at the Ronald Reagan hospital, which was opened on the UCLA campus in 2008, can be converted into intensive care rooms and all of them can be switched to negative pressure, which stops airborne germs from escaping the room. Similarly, after the Asian epidemic of severe acute respiratory syndrome (Sars) in 2003, Singapore and Hong Kong adapted their hospitals, equipping them and developing protocols so that they could be transformed quickly in the event of an epidemic.

The Ronald Reagan hospital in Westwood, California.
The Ronald Reagan hospital in Westwood, California. Every ward can be used for intensive care and airborne germs can be contained. Photograph: David McNew/Getty Images

The disadvantage of this approach is that the disease may erupt far from the hospital, so an alternative solution is to rapidly build a facility dedicated to the detection and treatment of epidemic patients where it is needed, as the Chinese did during Sars, completing the Xiaotangshan hospital in Beijing in just seven days. They replicated that feat several times this year, building Wuhan’s Huoshenshan hospital in 10 days, for example. Made out of prefabricated units, Huoshenshan incorporated testing and research labs and accommodation for personnel.

Other countries built fast too, in response to Covid-19. Surge hospitals went up all over the US last spring, while the UK constructed the temporary Nightingale hospitals. But many of these were underused or not used at all, sometimes because they were understaffed. Architect Huang Xiqiu of the China IPPR International Engineering Corporation in Beijing, who designed both Xiaotangshan and Huoshenshan hospitals, says that the facility alone is not enough: “A systematic approach should be followed.”

That involves conceiving of the temporary hospital as part of a larger city- or area-wide disaster prevention plan, organising on-site stores of medical and protective equipment, maintaining a roster of available, qualified staff and setting up an emergency command centre to oversee the execution of the disaster plan. It helped, in China, that the state assumed all the costs of the Covid-19 response.

Annmarie Adams, a historian of hospital architecture at McGill University in Montreal, says that it’s no coincidence the UK’s temporary Covid-19 hospitals are named for nursing pioneer Florence Nightingale. Architecturally, they mark a return to the “pavilion plan” favoured in the 19th century, when infectious diseases were still the biggest killer globally and ventilation was considered key. The original Nightingale ward had a barracks-like arrangement of bed-window-bed-window embedded, usually, in plenty of green space. After the advent of antibiotics, the pavilion gave way to the “hospital-as-office-tower” model, which bundled the specialties together in the name of efficiency and relied on those very antibiotics, along with hygiene, to keep infection at bay. Not surprisingly, this model has proved the least well adapted to a novel viral disease. “We became addicted to antibiotics,” says Mann.

If the hospital of the future is a specialist hub, digitally embedded in the community, those who specialise in infectious disease must also be capable of responding to an epidemic, meaning that they must have built-in flexibility. Luca Aldrighi, a hospital architect with RMJM Prague in the Czech Republic, envisages a pavilion-monoblock hybrid. “In my opinion, the future of the hospital is to take the best of these two layouts,” he says.

There are different ways of achieving that, but one way he could imagine is to have pavilions surrounded by gardens or piazzas and connected underground. In the event of a surge, the pavilions could be expanded into the surrounding space through the addition of modular units.

Hospitals don’t just reflect the evolution of medicine, Adams says. They are also shaped by wider cultural influences. Hospitals that once looked public, resembling prisons and other reform institutions, now look more like hotels, shopping malls or airports, reflecting a more consumerist culture. Nevertheless, she agrees that adaptability will be the watchword in the post-Covid-19 world, which has learned that it is still vulnerable to infectious disease. As she said recently: “I suspect hospital architects will focus on preparing for the unexpected.”

Hafta Ichi
Source: The Guardian
Keyword: Hospitals without walls: the future of digital healthcare

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