Designing for the new communications technology
Microrobotic surgery, virtual visualization, remote patient monitoring—a vast array of advanced medical technologies is about to transform how healthcare is delivered. But that's just the beginning. These new technologies are also transforming the built environment.
Admittedly, the healthcare industry is often portrayed as slow in taking full advantage of new technologies. Cost is one factor; investing in technology may very well be the largest capital expenditure on the hospital's balance sheet. The complex nature of optimally integrating the new technologies into hospitals is another. But there is no doubt that those who don't grasp what's on the horizon will be left behind.
In reality, the pragmatic expectation for today's new all-digital hospitals is “paper lite,” not “paperless,” until the community doctors' offices, nursing homes, and insurance companies have all upgraded to electronic medical records. In fact, there is still a transition period to wade through until both ends of the spectrum have installed the needed equipment. Clearly, though, the benefits of the effort far outweigh the challenges of moving into the digital and paperless environment.
How has the advent of wireless technology been a boon to hospitals? Pagers, two-way radios, wireless local area networks (WLANs), PCs, and cellular coverage are all part of today's “normal” medical environment. In fact, the devices now commonplace in daily life—cell phones, personal data assistants (PDAs), and tablet PCs—allow caregivers and patients alike to be free from the constraints of cords and cables and yet be constantly connected. These devices help nurses stay mobile while maintaining close communication with patients. Nurses have constant access to electronic charts, test results, physician care plans, and other caregivers, without being bound to a nurses' station.
Patients, too, are mobilized with wireless devices such as infusion pumps and are continually monitored via wireless technology for birthing, cardiac, and respiratory care—without the gaps that occur if equipment has to be disconnected and then reconnected when patients are moved.
But the move to wireless brings healthcare design challenges with it. For example, not surprisingly, wireless signals do not travel well through buildings. The “Can you hear me now?” scenario is unacceptable in a healthcare environment where lives are at stake. In fact, until recently, a separate in-building wireless signal- distribution system was required for each technology and/or service provider.
Today, better solutions exist. Hospitals can converge multiple services onto a shared wireless signal-distribution infrastructure often called a “wireless utility.” For example, the WLAN design at Dallas-based Methodist Health System's new Methodist Mans-field Medical Center consolidates Wi-Fi (wireless fidelity) access points into the technology room, located cosmetically out of sight from the corridors and patient spaces. As capacity requirements increase, the access points are added at the technology room. When maintenance is required, the work is completed in the technology room, not in the hallway, and therefore does not disrupt the patient care environment.
Then there is the problem of interference. How can wireless systems be developed to avoid having signals converge, mix, or scramble? Even two-way mobile radios in cars can affect wireless transmissions. Such was the case for one heart hospital that had received permission to build a structure over a public thoroughfare. The concern was that the operating rooms would get radio interference from low-power mobile radios in the cars below. An electromagnetic compatibility (EMC) engineering consultant was brought on board. The solution: An electrically grounded copper screen material was embedded around the building along with the installation of specially fabricated windows with high-tech RF-conductive layers. These steps created a barrier to incoming radio signals so that unwanted radio transmissions would not penetrate the building and interfere with medical equipment
But that presented another problem: Radios inside the building (EMS, two-way, fire, and police) could not receive intended signals from emergency and commercial broadcasters outside the building. The solution? A wireless utility system was deployed to reinforce the intended wireless signals within the building. This not only allowed cell phones and other wireless devices to be used inside the structure, but it distributed an even signal so that no calls would be dropped—a frequent complaint.
Critical to the success of a wireless utility installation is frequency coordination and appropriate antenna design; each is a must. No two wireless systems can use the same frequency, and sensitive wireless medical telemetry service (WMTS) signals must be protected. The signals must be appropriately routed to trap unwanted energy away from sensitive equipment. Meeting these requirements is guided by frequency mapping and good antenna design, both of which have become important factors in designing the new paperless (or paper-lite) hospitals.
The next step in wireless—the likelihood that every laptop will be wireless—will pose a new question: whether to offer high-speed wireless Internet access for free or for a provider fee to patients' family members and hospital visitors—just as some airports, hotels, and coffee shops offer their customers paid access. Again, cost will be a factor. Today, a wireless utility system for the new 152-bed Methodist Mansfield Medical Center will cost about $500,000. The hospital eventually will have to determine whether to recapture this cost from users or absorb it as a marketing expense. Another decision will be whether to offer wireless Internet access to patients. Would it cause patients who should be resting and recuperating to try to go back to work while still in the hospital? Or would it be a highly valued patient amenity overriding this concern?
Future Design Implications
As wireless technology strengthens its presence in hospitals, it will continue to affect work flow, environmental, and equipment requirements. Acuity-adaptable rooms, decentralized nursing concepts, and work-flow processes will be further refined, as will the designs needed to accommodate them.
In the past, medical-equipment planners obtained the owner's clinical requirements and medical-equipment specifications to accommodate the spaces the architect had designed, and then provided concise technical reports to the mechanical, electrical, and plumbing engineers, just as interior designers specify the furniture. In the digital and wireless age, the clinical systems, facility systems, and enterprise information systems will define the infrastructure and spatial requirements. This means that they should be planned in conjunction with the architectural and engineering design process; it would be much too late in the process to start this sort of planning when the bricks and mortar are already in place. And because these systems should “talk” together and exchange information gathered from patient rooms, laboratories, imaging, pharmacy, accounting, physicians' offices, clinics and, eventually, from outside healthcare settings, a multidisciplinary approach is needed to connect all the systems.
As these systems become more complicated, overall space planning is affected. A typical main telecommunications “closet,” for example, has grown from 900 square feet to 1,400 square feet or more. Many indirect factors drive the size of the space required. Inclusion of nontelecommunications technologies—such as gateway servers connecting medical devices and interactive TV programming systems to the system infrastructure, corporate backup server rooms for disaster preparedness, uninterruptible power supply requirements, and the need for computer-center HVAC—are a few of the modern variables. In short, the trend toward larger space is due to shared technologies. This is redefining the telecom closet as a “technology room.”
As if that weren't enough, the structured cabling systems themselves have often grown into a forest of confusion. One Northeastern hospital struggling for space deployed a lean-to room addition for telecommunications. Because the roof would “sweat” when the air-conditioning was on, plastic had been used to cover switching equipment. Compounding the situation, the all-black wires and cables stretched in a tangled pattern from one end of the space to the other; service equipment was stored between the racks of equipment, which prevented access for servicing; and the doors were often propped open to the street level for ventilation, allowing full access to anyone walking by.
The solution included a master plan for several technology rooms to support the hospital's current and projected growth. Planning the equipment spaces to permit full access to the equipment included diagramming an “above-ceiling” schematic to provide clear delineation of each system component and cable pathway for ease of maintenance. Color-coding the cables according to the systems served—often considered costly at 15% per cable per color jacket—was nevertheless used to provide readily perceived visual indicators for monitoring and maintaining the systems. Among other improvements, the master plan focused on providing adequate and properly positioned lighting. Finally, access-card readers were installed for security.
With so much at stake, both financially and operationally, an overall technology strategy is essential for integrating complex systems and fully exploiting their potential—whether for a new hospital or an existing facility. The healthcare designer's and medical technology planner's job is now much more than coordinating equipment with hospital spaces. It now means taking a global view of all technologies on a campus and ensuring that they are compatible, coordinated, and integrated. Only then will the healthcare facility be poised for success well into the future. HD
Steven Juett, PE, is Director of Clinical Systems Planning, and Martin McIntire is Vice-President, of EQ International, a medical technology, planning, and consulting firm based in Dallas.
An Early-Day Success Story
One facility that has embraced new technology is the all- digital Centennial Medical Center in Frisco, Texas. A new facility, it was specifically designed for total electronic work flow, as well as adaptability for film and paper records submitted to the hospital from physicians' offices and outside healthcare facilities. Recognizing the need to translate film and paper records, the hospital systems were designed to capture these manually processed files and scan or convert them to an electronic format (with the hospital then returning the paper file to the patient or provider).
Compared to a traditionally designed hospital, Centennial Medical Center requires less space for paper and film storage and more space for data infrastructure, electronic storage, electronic security, and high-tech medical equipment. Space beyond the patient room walls and ceilings was designed to accommodate the cables, special antenna systems, and network electronics necessary to support the all-digital technology. Operating rooms averaging 600 square feet were designed to house the most advanced surgical equipment, flat screen x-ray displays, vital-signs monitors, and even voice-activated technology.
A critical concern was making sure that the hospital technologies worked together as interconnected systems. Without this connectivity for data transport, much of technology's promise would go unfulfilled. Because this is a highly specialized and technical area, Centennial hired a specialized information management consultant at the beginning of the project to make sure that data would be integrated seamlessly. This involved creating and orchestrating hundreds of screens having department- specific information fields, as well as integrating dozens of applications, all of which were interconnected throughout the hospital. The investment in expert consultation paid off: When the doors opened, all pieces of technology and related programming “talked” with one another, as needed. Connectivity worked, as advertised.
It is important to note that because this was new construction, many of the challenges inherent in a digital conversion for an existing facility were solved before the project began. The challenge is much greater for adapting information management in an existing facility. The old data structure, known as a “legacy information structure,” requires a migration strategy for loading and running the data on new systems. In some cases, the total database needs replacement. With either an existing or a new structure, expert consultation will expedite success.
—Steven Juett, PE, and Martin McIntire