9/20/2010

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Defining the Challenge

John S. Milne, MD, MBA, FACEPMedical Director for Strategic Development

Swedish Medical Center

Seattle Washington

King County, WAA Case Study

King County 1970Population: 1,159,375

King County 2010Population: 1,916,441

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Flexible Models Rapidly Adapting to Change

The “Lite” Hospital

An Enhanced Ambulatory Center•Emergency Services•Ambulatory Surgery/Endoscopy•23 hours Observation•Imaging Center•Laboratory•Physician Offices•Physician Offices

King County 2020?Responding to Growth

Architecture &Evolution of theHospital Futureof

th

e

Richard M. Satava, MD FACS Professor of SurgeryUniversity of Washington

Healthcare Facilities Expo & SymposiumThe Navy PierChicago, ILSeptember 14, 2010

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Richard M. Satava, MD FACS

Financial Support: None (… but still hoping)

Presenter Financial Disclosure Slide

Consulting: Karl Storz

ISIS Support StrykerSimuLabUS Surgical

Investment InTouch Technologies, Inc

* There will be no discussion of products from these companies

“The Future is not what it used to be”

Disruptive Visions

The Future is not what it used to be

….Yogi Berra

Length of stay Decreasing , turn-over, follow-up?

In-hospital procedures Ambulatory centers, LOS,

chronic care

New Approach to Healthcare

Advanced technology Rapidly changing

Specialty units Redesign, reconfigure

System of Systems Complexity, integration, access

Accountability Audits, reports, training (sim-center)

Totally integrates (Admin, ER, OR, Central Supply, Risk Mgmt)

Hospital Information Systems

System of Systems (Admin, patient care, pharmacy, surgery)

Ubiquitous access (computer terminal, cell phone, ER/OR)

Continuous visibility (RFID, bar code, videocam, EMR)

Super computer/store (Imaging, massive records, simulation)

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The Revolutionary Change

Well, maybe not all people understand the rapidity of change

SimulationMEDICAL RECORD

as

HOLOmer - HOLOgraphic Medical Electronic Representation

Emergency Room Trauma Portal

+ TRAUMA PORTAL +

Virtual Autopsy . . .

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Total Integration of Surgical Care

Minimally Invasive& Open SurgeryRemote Surgery

Courtesy of Joel Jensen, SRI International, Menlo Park, CA

Pre-operative planningSurgical Rehearsal

Intra-operative navigation

Simulation & TrainingPre-operative Warmup

From tissue and instruments

t

The Fundamental Change

to

Information and energy*

* “The Information Age is about changing from objects and atoms to bits & bytes”Nicholas Negroponte “Being Digital” - 1995

Courtesy Larry Crum, Univ WashingtonApplied Physics Lab2003

The LSTATLife Support for Trauma and Transport

“ . . . with a fully functional ICU ”

• Defibrillator

• Ventilator

• Suction

• Monitoring

Total Patient Awareness

Bring the hospital to the casualty, not the casualty to the hospital . . .

Courtesy of Integrated Medical Systems, Signal Hill, CA

Monitoring

• Blood Chemistry

Analysis

• 3-Channel Fluid/Drug

Infusion

•Data Storage and

Transmission

• On-board Battery

• On-board Oxygen

• Accepts Off-Board

P d

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212th MASH Deployed with LSTAT - Combat Support Hospital

LSTAT Deployment to Kosovo - March 2000

Courtesy of Integrated Medical Systems, Signal Hill, C

LSTAT- lite

Natural Orifice Transluminal Endoscopic Surgery

N.O.T.E.S.

Courtesy of N Reddy, Hyperbad India 20005

Endo-luminal MalignanciesRobotic Endoscopic Mucosal Resection - EMR

Courtesy of N Reddy, Hyperbad India 20005

What next?

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NOTES - for Bariatric Surgery New Concepts for OR of the Future“The OR Without Lights”

Eric LaPorta, Barcelona, Spain 200

Demonstration of Phase 1

Operating Room with No People

SRI International, Menlo Park, CA January, 2007

Demonstration of Phase 1

Operating Room with No People

SRI International, Menlo Park, CA January, 2007

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Robotic Medical Assistant

Nursing shortage crisis

SATAVA 7 July, 1999DARPA

Applicable at all levelsHospitalsClinicsNursing HomeAssisted living

Courtesy Yulun Wang, InTouch Technologies, Inc, Goleta, CA

Radiology or Surgery?

Accuray(Cyberknife)

Non-invasive tumor ablation for solid organs (0.3mm accuracy)

Surgeon should be part of planning and implementation team

Surgeons may want to ‘adopt’ implementation

(Cyberknife)

The Information Age is NOT the Future

SATAVA 7 July, 1999DARPA

The Information Age is the Present ...

There is something else out there . . . .

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What is radically new?Biomimetic Micro-robot

Courtesy Sandia National Labs

Capsule camera for gastrointestinal endosco

Courtesy Paul Swain, London, EnglandCourtesy D. Oleynkov, Univ Nebraska

Core capsule systems: optical system, telemetry and power systems, navigation etc.

Diagnostic system:

xternal magnetic guidance

Self-propelling Gastrointestinal EndoscopeCore functions

Locomotion Modular functions

system:sensors for enhanced diagnosisTherapeutic / biopsy system:devices for tissue manipulationLocomotion system:actuators for mobility.

Supported by the European Union as an Integrated ProjectInformation Society Technologies - Contract Number 033970www.vector-project.com

Courtesy Marc O. Schurr &The VECTOR consortium - 2008

Fluid environment

Vibratory locomotionWalking robot with legs

nternal Locomotion Actuators Currently Investigated

Submarine

Source : A Menciassi et al., CRIM, Scuola Sant‘Anna, Pisa

Source: M. Sfakiotakis et al., FORTH, Heraklion

Supported by the European Union as an Integrated ProjectInformation Society Technologies - Contract Number 033970www.vector-project.com

Courtesy Marc O. Schurr &The VECTOR consortium - 2008

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Femtosecond Laser(1 x 10 –15 sec)

Los Alamos National Labs, Los Alamos NM

Cold Spring Harbor Laboratory, Long Island, NY

Time of Flight Spectroscopy

Cellular opto-poration

Surgical Console for Cellular Surgery

Courtesy Prof Jaydev Desai, Drexel Univ, Philadelphia, PA 2005

Motion C d

Surgical Console for Cellular Surgery

Courtesy Prof Jaydev Desai, Drexel Univ, Philadelphia, PA 2005

Commands

Molecular Imaging BioSurgery

Courtesy: Rahul G. Thakar, Ph.D. 2007

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AFM of DU 145 cells after sonoporation IMSaT DundeeAtomic Force Microscopy AFMSonoporation of an ion channel OR of the Future Current

Exoskeletons

Surgical Cockpit

Intelligent Prostheses Tissue Engineering

Replacing Human Body Parts

a) Rheo Bionic knee Ossur, Reyknavik, Iceland

b) C-leg Otto Bock, Minneapolis, MN

Liver Scaffolding Artificial Blood Vessel

J. Vacanti, MD MGH March, 2000

Artificial Ear

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Organs which have been grown synthetically

urothelial and smooth muscle cells that are capable of regeneration are isolated.

The isolated cells are cultured separately until there are a sufficient quantity.

The cultured cells are properly seeded onto a biodegradable scaffold shaped like a bladder.

A surgeon takes a small, full-thickness biopsy from the patient’s bladder.

Neo-bladder – a commercial synthetic bladd

Commercial Products

q y p

Quality assurance that the cells attach and grow properly throughout the scaffold. After about 8 weeks, the neo-bladder construct is returned to the surgeon for implantation.

The neo-bladder construct is implanted by the surgeon using standard surgical techniques.

The body uses the neo-bladder construct to regenerate and integrate new tissue, restoring the bladder’s functionality.

The biodegradable scaffold dissolves and is eliminated from the body, leaving a functioning bladder made only of the patient’s own newly regenerated tissue.

p

Courtesy of Tengion East Norrington, PA 2007. Tegion,

Institute of Arctic Biology’s

Toolik Field Station,

Alaska's North Slope

Suspended Animation (Auto-anesthesia – FRAMR)

active hibernating

heart rate 300 3

Brian M. Barnes, Institute of Arctic Biology , University of Alaska Fairbanks 11/02

metabolic rate 0.5 0.01 (2%)

body temp. 37oC -2oC

gene ongoing transcriptionfunction and translation suppresse

heart rate 300 3

resp. rate 150 <1 (breaths/min)

(beats/min)

(mlO2/g/h)

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Hypothesis

Design

Experiment

Results

The Scientific Method… make evidence-based decisions

Report

In Science and Discovery,there is always Risk . . .

Be careful ofunintendedconsequences

The only thing more dangerousthan trying too hard and failing …

… is not trying hard enough

and succeeding ! Michelangelo 1503

Experience is the name everyone gives to their mistakes - Oscar Wilde

It’s Not about the BuildingIt s Not about the Building…

Thom Kurmel, DDES, RAFormer Senior Advisor to the Assistant Secretary of 

Defense for Health Affairs, Washington, DC

TDK Consulting, LLC :: Lorton, VirginiaThom.Kurmel@Gmail.com :: 703.967.0131Disabled Veteran Owned Small Business

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Swimming Up Stream

• From

From 2009 “Innovative 21st Century Building Environments for VA Health Care Delivery” National Institute of Building Sciences (NIBS) report for the Veteran’s Health Administration

Begin Transition Planning Now

Adapted from the US Army Health Facility Planning Agency and Mercury Healthcare Consulting

TransitionPlanning

Its Not the Building’s Fault

Adapted from the US Army Health Facility Planning Agency and Mercury Healthcare Consulting

Caveat Emptor

• Rapid Prototyping• Component Testing• University Labs

Adapted From Mercury Health Care Consultants

• Health System Labs• Outside Labs

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Medical Facilities Life Cycle Management

Data Collection

Mission Market Assessment

Business PlanPopulation (RAPS)

Workload (MEPRS/CHCS)Staffing (TDA)

FacilitiesData

Space UtilizationCapacity Analysis

Architectural CADD DrawingsSite Drawings

List of Current ProjectsHistorical BackgroundCost Option Studies

Enrollment (MCFAS)Utilization (M2)

Site/Facility/Capacity Analysis

Mission Business Plan

Bio-Safety LevelsResearch Population

Animal PopulationResearch Focus

Equipment-driven Space

Animal ModelsUtilization

Throughputs

BusinessMarket Analysis

Demand Analysis

Master Planning Process

FOUO – Predecisional - FOUOCOL Kiyokawa / MCFA /(210) 221-8077 (DSN 471) / guy.kiyokawa@us.army.milSlide 57 of 6157

Facility Project Scope and CostFacility Project

Scope and Cost

CapitalProposals

Constraints & Opportunities Existing Program Capacities

PhotographsSite and Accessibility InfoInfrastructure Assessment

ArchitecturalEngineering Systems

EquipmentAT/FP

Provider RequirementsVolume Thresholds

OptimizationFunctional Alignment

Planning Scenarios

Capacity AnalysisSpace Program

Functional Options

Researcher RequirementsPhasing

OptimizationFunctional Alignment

Protocol Durations

Capacity AnalysisSpace Program

Functional Options

SpaceRequirements

Forecast

SiteAssessment

Planning Scenarios

Slide 4 of 8

Right Brain Activity Left Brain Activity

Communicate and Share

For the The US Military Health System (MHS)

Plan for Transition“If you don’t know where you are going, you might 

end up someplace else”…Yogi Berra

TDK Consulting, LLC :: Lorton, VirginiaThom.Kurmel@Gmail.com :: 703.967.0131Disabled Veteran Owned Small Business

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At the 2009 Healthcare Facilities Symposium and Expo in Chicago, I invited a

group of manufacturers, designers and builders to come together and to

collaborative address three problems confronting the healthcare industry:

1. Solutions for the healthcare environment MUST empower multidisciplinary team

collaboration! Today, they often fail to so this, optimizing the pieces rather than the

whole.

2. Technologies should be decoupled from architecture. Imagine not needing a

headwall at all. Imagine how much simpler, less expensive and flexible the

architecture would be without embedded technologies that became obsolete well

before the space did. Think USB in the computer industry – one standard that

allowed for many technologies to interface with any computer that accepted the

interface.

3. Buildings should be more manufacture-able. Think a kit of parts, quicker to deliver

with higher quality and spatial standardization, while still allowing for design

freedom.

Designers

Devenney GroupPratt Design StudioHGABahr ArchtectsTed Jacobs Engineering Group

BuildersSymphony LLCWatermark Solid SurfaceBuilders Watermark Solid SurfaceJE Dunn Construction

Manufacturers/Sponsors

Integrated Medical Systems (LSTAT)ConXTechDIRTTDuPontGerflorRice University Building InstituteHealthcare Facilities Symposium and Expo

Healthcare continues to be an overwhelming economic burden on the US and beyond

Growth in cost burden is not balanced with quality of outcomes and is not sustainable Cost burden on US equates to greater than 17% of GDP. In

effect, this burden threatens US global competitiveness.

P j t d t ti t i t t t th th Projected costs continue to increase at a rate greater than the GDP itself

Widespread staffing shortages indicate that we couldn’t even staff the projects we are currently planning

National debate threatens to further polarize our society, with potentially destabilizing consequences

A small group set out to bring an integrated set of solutions, addressing all three problems in an integrated prototype to the 2010 Healthcare Facilities Symposium and Expo.

Early on, they determined that a “Patient Room of the Future” was a tired cliché and determined therefore not to build one.

They focused their energies instead on developing their manufacturing model and technological application on a universal

it d l th “ h t t ” t f th t i lik l tcare unit module – the “short stay” aspect of space that is likely to see high volumes of services in simplified spaces.

By integrating clinical technologies into the care platform, continuum of care is greatly increased within and between environments

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The group embraced essential guiding principles that were to be embedded into any proposed prototype solution:

Healthcare services (value) pulled to patient

Collaborative care team model (optimizing efficacy, efficiency, transparency)

Better patient outcomes (increased safety, decreased risk)

Continuity of care from point of injury to recovery

Care team and patient situational awareness

Adaptable, flexible clinical environments

System integration that enables quick changes in care delivery

Manufacture over construct

Increased speed

Minimize material waste