Building for the Future

April 10, 2013
Rodney Dykehouse Though the building boom in the United States has grinded to a halt, one segment continues to grow. “Healthcare continues to be
Rodney Dykehouse
Though the building boom in the United States has grinded to a halt, one segment continues to grow. “Healthcare continues to be very, very strong,” says Jim Koehler, director of specialized services for Minneapolis-based HGA Architects and Engineers. “Right now, not a lot of companies are building new headquarters. But healthcare does not go away.”

The need for new facilities comes from a convergence of factors, says Koehler. “A lot of the community hospital activity involves the replacement of an existing hospital built in the ’40s or ’50s that can't run efficiently anymore for numerous reasons.” He says that rapidly expanding communities have created new geographical opportunities as well – and added to the mix is patient-centric care that demands hotel-like amenities, and the increasing competition to woo voluntary doctors with physician-friendly technology.

John McDaniel, the new CIO of St. Vincent Catholic Medical Centers (St. Vincent's) in New York City, saw the need for new building as soon as he arrived. “I think a lot of CIOs miss this point. But when I first got here I did an assessment,” he says. “One of the quick conclusions I came to is that if we don't redo our technology infrastructure, we would never be successful.” For McDaniel, facing strong competition in hospital-heavy New York meant a new, state-of-the art facility.

This hospital boom — and the costs it brings with it — isn't ending any time soon. With an aging population in need of more care in updated facilities, and the increasing costs of construction today, hospitals can easily see their capital budgets swallowed up by building costs. And even the slightest delay or snafu can cost a hospital big bucks. So how can these be avoided, or at least, lessened?

For most CIOs, the biggest challenge is predicting the future. With IT so deeply entwined in both financial and clinical operations, it appears CIOs can't leave it to the architects to make predictions.

The UCLA Medical Center in Los Angeles opened its new Ronald Reagan Pavilion designed by architect I.M. Pei this July, after a 10-year building process. According to CIO Rodney Dykehouse, he learned a few valuable lessons prior to the ribbon-cutting ceremony.

“I think it's a general problem between construction and architectural firms that their guidelines for scoping out technology requirements is historically based,” he says. “From an IT standpoint, the IT people must get in front of the architects and the construction people and project forward.”

He echoes other CIOs who say today's architects don't seem to get it when it comes to network closets and data center requirements for power and cooling. Most CIOs understand that even though computers are getting smaller, that fact is counteracted by the demand for more technology and applications. The truth is that even as computers get smaller, they still have the same or comparable power and cooling requirements. “Anybody going down this path has to be able to figure that out in advance, because once the facility is built, you're stuck,” says Dykehouse.

Koehler says the disconnect between designers and CIOs is real. “I see it all the time,” he says. “Architects and engineers have been in the business for a long time, and it's hard for these folks to recognize how much of a change there is from a technology perspective, and how that changes a building and how it operates.”

Lindsey Jarrell
Often, these changes can be substantial. At St. Vincent's, for example, drop-down computers will allow patients to access the Internet, send e-mails, watch TV or movies, raise and lower the blinds and lighting, and call the nurse — all from a single device. In addition, nurses will use the same computer for documentation. St. Vincent's is also in the process of getting its first EMR installed in the new building (as of publication, the vendor has not been finalized).

To generate enterprise support for IT in the new hospital, McDaniel has built a demonstration suite in the old facility that's entirely digital and paperless. “We really designed it to allow people to envision what it would be like to work in that kind of setting,” he says. “The users are starting, in their minds, to change their process and to think about how patient flow would be in a digital facility.”

At North Memorial, a two-hospital system in Robbinsdale, Minn., CIO Pat Taffe also built a demonstration unit for his new 90-bed Maple Grove Hospital — in a warehouse.

“A lot of it had to do with the placement of the devices,” he says. Over the course of a few months, staff from almost every department in the hospital, including physicians, clinical staff, maintenance, and environmental services came through the demonstration unit, and Taffe made tweaks based on their feedback.

“We raised the workstations by two inches one week, then lowered them for the next, trying to get the optimal height.” He also trialed bedside and computer monitors on both sides of the bed. “There was a lot of work that went into trying to make sure that the technology we put there would not only do the job, but that it was positioned so doctors, nurses, and staff could do their jobs too.”

In addition to all the latest in amenities, most hospitals being built today are paying special attention to wireless infrastructure. “I think any facility moving forward has to put in high-speed backbones,” says Dykehouse, who is using a San Jose, Calif.-based Cisco system. “They will have to begin to really build out their wireless network.”

With the increased use of wireless in new facilities, he says, wireless management systems are needed to provide a real-time overview of the wireless network that can see where devices are, check out the coverage, and remotely tune the wireless network system. Hence, Dykehouse is implementing a wireless management system at the Reagan facility.

“There needs to be a focus not just on implementation, but on the management of the systems, with the ability to respond, adjust, and tune these systems immediately,” he says. “That's the type of thing that will become more critical as more and more medical devices are implemented,” explains Dykehouse.

McDaniel has plans for the medical devices at St. Vincent's as well. He will have USB ports that plug directly into the various medical devices in the room. “So as opposed to the nurse actually having to document the information on a device, it will populate the patient chart electronically,” he says. “All she will do is verify.”

As PACS has moved into the mainstream of the hospital specialties, and CT scans move from 32- to 64-bit (and up), bandwidth is also an important consideration. At Maple Grove, Taffe has what many say is the best solution to the bandwidth issue — the hospital has laid its own dark fiber.

“It isn't cheap,” he says. “It's very expensive to have your own private fiber, but we felt that we could easily pay it back in five years by not paying rent for fiber.” Taffe says that will allow his hospital a virtually unlimited amount of bandwidth in the future.

Most CIOs involved in a new construction project are also spending a lot of time on device, communication, and application integration. Lindsey Jarrell, CIO for Tampa, Fla.-based BayCare Health System, a nine-hospital system, is using U.K.-based Philips' Emergin integration engine. He says nurses today can have pagers for nurse call, pagers for general communications, an internal wireless phone, a PDA to check drug-drug interactions and a computer on wheels (COW). “We want to take things down to one mobile device like a PDA that has phone capabilities, put it all on one device and also give them access to corporate e-mail.”

Integrating new applications into a new facility is challenging, but what about legacy systems? Does a new facility represent an opportunity for “all new”? Apparently, not many CIOs are going that route.

At UCLA, Dykehouse is putting together a new clinical portal from Orion Health (Santa Monica, Calif.) so clinicians don't have to search through multiple systems. “Many of our systems, good or bad, have been custom-developed over the years, so that's part of the challenge — we have to refresh our application portfolio.”

At St. Vincent's, McDaniel, in a sense has it easy — he has no EMR. “We don't even have order entry. It does simplify things to a great degree because basically I have no legacy applications out there, or very few that I have to convert from.” McDaniel says he does plan to preserve the few legacy investments he has by creating an application programming interface (API) that can be accessed from anywhere.

Though most agree that wireless technology and patient-centric rooms are the most popular elements in new hospital design, today's CIO has a wealth of IT opportunities to choose from, which in itself can present another challenge. “The technician in us is always drooling about virtualization, blade servers, RFID, Vocera, and all these technologies,” says Taffe. “But we made a decision early on that technology was going to be prevalent, but not overly evident. We were not going to deploy technology for the sake of a new toy to play with.”

One area he decided to downsize was RFID. Since it's possible to track virtually anything in a hospital, the project was a bit overwhelming. So Taffe says he opted to move into that area slowly. “We decided not to put RFID into everything that moves the day we opened up the hospital.” He says although there is certainly value in being able to track everything, it is costly. “We decided to make sure we're using it where we can get the most benefit.”

For Taffe, that meant tracking devices and equipment that nurses need at the bedside, but can never seem to find—like wheelchairs and IV pumps. “Our goal is really for technology to anticipate the needs of the caregivers, versus them telling us what they want, and then we go off and do it.”

The green movement has also taken hold in the hospital building arena. “The phone PBX is a good example,” says Jarrell. “It went from the size of a car to the size of a chair. So that requires less heat, less cooling.” His new hospital will be LEED certified silver (see sidebar).

Another green option is virtual machine software that runs more applications off less servers. “It reduces footprint, it reduces square footage requirements, it reduces energy requirements, it reduces the heat, and it truly reduces my cost because I don't have to buy as many servers,” says McDaniel.

At MapleGrove, Taffe is using blade servers to reduce his footprint. “We've been very conscience about greening this facility. Virtualization is in the strategic plan, and the hospital will open with virtual servers.”

For CIOs, the constant battle of how much space they can allocate for technology is a big challenge. But there's an even bigger one.

“How do I make sure we are not designing ourselves into a corner?” says Taffe. “We don't want to over-design, yet we want to try and anticipate what the future may be.” Taffe believes he found a solution by focusing on the core of the hospital. He says that although server size and heating, cooling, or powering requirements might change over time, the organization would be okay as long as he could “secure space in the core parts of the hospital so that we can move vertically or horizontally out of those communication rooms.”

Listening to peers, site visits, and extensive research also pay off. Jarrell says he and the six technology directors that report to him dedicated time into looking at IT evolution. “We spent a lot of time thinking, ‘How has technology changed in the last 5 or 10 years, and how could we have envisioned the future 10 years ago?’”

Jarrell says his team spent time with technology futurist Jeff Goldsmith of Health Futures Inc. (Charlottesville, Va.) to get an idea of consumer demands and how they might be changing. “Goldsmith helped us understand not so much about where technology is going, but where the demands of the consumer are going. Because the consumer will create the vacuum that technology will fill,” he says.

The other big challenge in building, says Dykehouse, is changes that users keep requesting. “The target keeps moving,” he says. His greatest challenge was the 10 years it took to complete the new facility. Medical technology changed, along with its workflow. “From an IT standpoint, we had to create a freeze and say no more changes because we've got to build this. It wasn't a brilliant decision, it was out of necessity,” he says. “We just reached a point where we spent more time figuring out what the requests and changes were, than we were getting things done.”

Koehler has some simple advice for CIOs who are taking on a building project. “I think every CIO knows they need to be on top of what technology is being used in their marketplace. That is really the key,” he says. “Understand what it is and how it applies to your building, and make sure you plan for it. It's not just IT people anymore.”

Dykehouse says you can't let the architects scope you down in size for data center or closets. “You need that network closet. That's a key issue,” he says. “If they use their standards, which are historical, you're going to be in trouble day one.”

Thinking about the future is a common theme for most CIOs on this path — and finding a partner to help can pay off. “Get out of your comfort zone and find an innovative consulting partner that can really make you think about the future,” says Jarrell. “The consultants we used were very traditional and wanted zero risk. I actually had to put my foot down with going for VoIP in this facility because they kept telling me it was an unproven technology.”

Koehler adds, “I think in the past, IT groups were more simple and went and did what they thought was appropriate. Today it's a little more complicated than a phone and a PC on a desk.”

Healthcare Informatics 2008 September;25(9):18-24

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