Co.Design

For the Future of Health Care Design, Look Beyond the Hospital

Our infrastructure is set up to rely on high-cost facilities. But lowering costs will require small-bore treatment at a new type of facility.

[Here, Jean Mah and Robin Guenther, two health-care design experts at architecture firm Perkins + Will, look at what the future holds for our health care system. ?Ed.]

The United States is facing a crisis of epic proportions in health care delivery. While the system celebrates cutting-edge technology and clinical excellence, it is also complex and chaotic, costs too much, and borders on irrelevancy for many of the health issues of our time. If that's not enough, the delivery of health care is energy- and water-intensive--not only are health care organizations now among the largest employers in their communities, they are also frequently among the largest consumers of resources.

The crisis is appearing on many fronts simultaneously:

-a funding gap (we can't afford the care we want)
-a human resources gap (there aren't enough medical practitioners)
-an energy gap (it's the second most energy-intensive sector)
-a carbon gap (as pressure to reduce carbon emissions builds, the system continues to have many transportation and supply chain inefficiencies).

One might say that the health care system is finally encountering limits.

Today's health care delivery system was developed in an era of infectious disease, trauma, technological breakthroughs, and the rise of medical education; it is not optimized for the day-to-day management of 21st century chronic diseases. It is huge, unwieldy, and it lacks agility. It is not about health promotion or disease prevention; it is optimized for disease treatment.

Is this affordable using today's delivery system? Absolutely not.

A recent New York Times article quoted Clayton Christensen: "Health care hasn't become affordable because it hasn't yet gone through disruptive decentralization." What does that mean? Disruption in health care entails moving the simplest procedures now performed in expensive hospitals to outpatient clinics, retail clinics, and homes. Costs will drop as more of the tasks currently performed only by doctors will shift to nurses and physicians' assistants. Lower-cost venues and lower-cost caregivers will make our system more affordable and accessible.

Technology
Technology is also profoundly changing--it's moving from being concentrated at the point of care in the hospital to being in the hands of patients and caregivers. For the last century, technology has been geared toward replacing the dialogue between the patient and the physician--designed to reveal the "truth" about medical conditions that most consumers can barely comprehend.

But chronic disease management challenges even this and requires consumers to participate in maintaining and managing their health--often on a day-to-day basis. Yes, it's the smartphone, iPad communication revolution, where technology becomes an enabler of positive social and environmental change. What does this mean? Last year, Kaiser Permanente delivered 5 million visits via videoconference (Skype), telephone, and email. Shifting health care from a "point of service" clinical model to an ongoing dialogue between patients and their providers is a profound societal and technological shift.

Disease Management
Chronic disease management--e.g. asthma, diabetes, obesity, and increasingly, cancer--is suited to this emerging two-way dialogue; in fact, "pushing health care" may well prove to be essential to bringing the epidemic of chronic disease under control. Obesity is the prime example: Today, in many states, more than 30 percent of adults are overweight or obese; the CDC estimates that annual medical costs for these Americans are in excess of $147 billion. If the current trend continues unabated, by 2030 more than 87 percent of Americans will be overweight or obese, with annual medical costs in the range of $860 to $956 billion.

Shifting from "point of service" clinics to an ongoing dialogues is a profound shift.

Is this affordable using today's delivery system? Absolutely not. Creative, low-cost ways to deliver health care to Americans with underlying chronic conditions must be developed alongside wellness and prevention services to the healthy population. This care must be convenient for both caregivers and patients, and delivered in a way that promotes individual compliance and responsibility. Providing care in retail malls, schools, urgent care clinics, and at home, rather than in higher cost hospitals represent the beginnings of a transformation.

Public Policy
The U.S. health care system is also beginning to engage in public policy debates that improve public health, such as advocating for removing routine use of antibiotics in meat production and reforming food policies that support unhealthy food product choices. The work of non-profits such as Health Care Without Harm, Practice Greenhealth, and the Healthier Hospitals Initiative suggest a growing policy and advocacy agenda for the health care sector, ranging from food to pharmaceutical management and waste reduction to toxic chemicals avoidance.

Infrastructure
Finally, there's the building infrastructure. The aging hospital infrastructure that the U.S. put in place at the end of World War II is continuing to be replaced. There has been a shift from semi-private to private patient rooms, accommodating the sophisticated diagnostic and treatment technologies that have accompanied significant medical breakthroughs.

An emphasis on natural lights and views, flexibility, and adaptability in hospital rooms have given way as hospitals have moved on to artificial lighting and ventilation systems, often equipped with emergency lighting, diesel generators, and double- and triple-backup systems. Extreme weather events like Hurricane Katrina illustrate the lack of resilience of our medical infrastructure--every hospital in New Orleans closed and none could provide essential food and potable water to their infrastructure-challenged communities.

In a future with increased instances of extreme weather, health care facilities should be equipped to deliver essential medical and public health services: they should be resilient. On-site renewable energy systems and water storage and treatment capability are examples of strategies that will better equip hospitals to perform in times of infrastructure crises.

Can health care occur in low-impact home settings?

At the same time, while there will always be the need for high-acuity, high-technology hospital buildings, the question is whether the majority of health care encounters can be facilitated in low-impact, low-energy community and home settings. As health care systems measure and examine their energy use and carbon profiles, they are learning that the transportation costs associated with care delivery use as much energy as the buildings themselves and both may well be dwarfed by the environmental impacts associated with supply services and waste disposal. The health care sector should not have to argue that delivering high-quality services necessarily entails excess waste production, toxic chemicals, and the disproportionate use of energy and potable water or that saving lives stands apart from the broader concerns of the environment.

Conclusion
The conditions are in place for a revolution in health care delivery--moving from a focus on disease care to maintaining health and wellness. It is time to imagine a new role for the health care sector, one that moves beyond saving lives in crisis to improving health while restoring ecosystems and regenerating social and natural capital. From sponsoring farmers? markets to launching community-based exercise and wellness programs, the health care industry is uniquely positioned to model health and wellness in a society in need of alternatives to fast food and sedentary lifestyles. We deserve nothing less from the industry best positioned to protect our health.


Jean Mah, Health Care Global Market Leader of Perkins+Will, is recognized as a leading expert in the planning and design of complex, state-of-the-art health care facilities, bringing transformative ideas to a variety of health care planning and design projects. Throughout her 30 year career, she has become a recognized national expert in designing flexible environments that encourage collaboration, accommodate advanced technology, and support leading research to develop cures for the most challenging illnesses. Jean's projects have received AIA | Modern Health Care Design Awards, Regional and National AIA awards, and has presented and been published in a number of national publications. Robin Guenther, a principal at Perkins+Will, is a national leader in the conversation on health care environments, specifically the conversation linking public health, regenerative design and sustainability. She has been named the Most Influential Person in Health Care Design by Healthcare Design Magazine and has received numerous awards for her work.

[Top image by Clever Cupcakes]

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2 Comments

  • Renata Maslowski

    Managing chronic diseases is certainly a key. There have been great strides in severe illnesses, like cancer and HIV, that now allow patients to live with their diseases and be productive.

    There is certainly a fundamental breakdown in healthcare delivery, from annual health check-up to patient management in the hospital that can be summed up as: inefficient use of time.

    Having patients wait, sometimes hours or days, for care after a diagnosis is stressful, and negatively impacts patient outcomes. If you make a reservation for any other service (think retail), you expect and receive that service usually on time. Not so in healthcare, where patients have to work around their own schedule to get service.

    What is difficult to do, does not get done. Making healthcare service difficult and time consuming, makes people avoid it until there is no alternative. Offering "quick+quality" care is the way of the future.

    Teaching people how to read the signs and symptoms from their own bodies will help the communication between patient and care-giver. Healthcare literacy needs to be a focus to improve care. Example: Robitussin cough medicine did a recent TV commercial that shows a monkey picking their symptoms to narrow down there medicine choice. It implied that self-care is EASY! More efforts should be made like this poll-based approach, especially with social media tools.

  • Bernard Farrell

    If we don't solve the challenges of chronic disease management, I think the other efforts won't make a difference. Look at the recent estimates for diabetes rates in 2025, the numbers are staggering.

    Chronic disease management only works if the patient (consumer) is empowered to take control of their care and disease management. We'll need an infrastructure that enables collection of measurement data (for diabetes: blood glucose measurements; insulin dosing, etc.) and creation of dashboards that integrates this into an overall picture with suggestions for the consumer based on what's worked for them, and the larger community, in the past. The dashboard needs to alert the healthcare team and user when challenges have or are occurring.

    And remember all of this will only happen if the FDA allows it. It's also rooted in 20th century practices.

    Notice also the industry needs to think about the user as a consumer first and a patient second, otherwise the results won't be attractive, engaging and usable.