Healthcare IT Lessons Learned
By Don Kinser, PE
I want to share some thoughts and ideas regarding low voltage in healthcare and some “lessons learned” over the years. My “low voltage” perspective comes from an information technology and communications point of view.
The first important lesson is to understand the key drivers in healthcare IT. I think there are three fundamental drivers at work in the industry today: (i) the industry’s slow and persistent march toward the goal of a full electronic health record, (ii) the promise of increased workflow efficiency and (iii) improved patient safety through IT adoption.
These three forces drive nearly all IT decisions in hospitals today. They also have some profound capital and facility implications. Here are a few to think about, in no particular order:
Data Centers
Data centers are a big deal! As hospitals continue the inevitable march toward a full electronic health record, the demands for storage are skyrocketing as more and more patient information is generated and stored digitally. Furthermore, as the clinical care process depends ever more completely on stored digital information the demand for ultra high reliability access to the stored information is also soaring.
The biggest shortcomings we see are the lack of sufficient reliability and redundancy. Very few hospitals have redundant data centers. Now that clinical care depends on the data, the data center cannot be allowed to go down.
This is a train that is about to run over the healthcare industry. Sadly, we see only a small percentage of hospitals that are even aware of the trouble they are in and fewer still that are actually working to address it.
Healthcare IT Today Demands More Real Estate
This is a big issue and one where we see inappropriate corners cut all the time. Proper IT in a hospital today requires significant square footage -- about 1% of the GBA just for the IT communications rooms throughout the hospital. This does not include the server room or data center. That’s at least 800 square feet of additional space, if not more.
The days of the data “closet” stuck in a corner of the soiled utility room are long gone. For a good discussion of this topic see ASHE’s proposal to the NFPA revision committee at http://ashe.org/ashe/codes/nfpa99/tech/
It is not just about what is in these rooms on day one when the hospital opens but the needs of the hospital in 5, 10, 15 years that we must also consider. We know information requirements are growing exponentially, and the healthcare industry continues to expect more efficient ways to improve outcomes. The way to achieve this is through better and faster technologies.
Oh and don’t let the hospital talk you into separate spaces for the IT and other things like security, nurse call and Biomed. In a converged future this won’t work.
IT Spaces Demand More Reliable Power and Cooling
The amount of power needed in IT rooms has dramatically increased over the past several years. One big reason for this is “Power over Ethernet” (POE). POE is used to power devices like IP phones, wireless access points, and other end user devices over the data cable through the network switch. It is not unusual today to see a 20 kW load in a typical IT room out on a floor due to POE demands.
Because phones, wireless access points and other important end user devices are powered through POE and the near total reliance on the network to provide clinical care (communicate results, view images, etc.), UPS power is now a necessity. This begs the question: central UPS versus the maintenance nightmare of small rack mounted battery units throughout the hospital.
All this equipment must be kept cool. The HVAC systems serving these spaces must not only handle an increased load but run on emergency power.
NOTE: the cooling load associated with POE power does not add to the HVAC load in the IT space except for the inefficiency of the transformers.
This power is consumed and turned into heat throughout the hospital where the end user devices are located.
Nurse Call Isn’t What it Used to Be
Simple code compliant nurse call systems are a thing of the past for most hospitals. The workflow advantages and increases in patient satisfaction and safety from improved nurse-patient communications compel most hospitals to invest in a more robust and feature rich nurse call system. Today’s nurse call systems integrate tightly with HIS systems, wireless phones and other personal communications devices (i.e. Vocera). Many also have staff tracking and locating features. The integration with such communication devices allows quicker, real time communication from patient to nurse, nurse to physician, etc. and saves time. Integration with other HIS systems avoids costly duplication of data entry and fewer medical errors.
All of the major nurse call manufacturers are working on IP based systems that will run over the hospital’s data network further improving the integration with other systems. However, the implication of this is IT must take ownership of the nurse call systems which has typically resided in the facility engineering side of the house.
Nurse call is a big deal and the technology is changing rapidly. Simply leaving it to the electrical engineer to specify a nurse call system isn’t the best idea anymore.
Don’t Confuse Infrastructure with HIS Systems
Today, hospital CIO’s and IT staffs are quite focused on implementing significant HIS software as they strive to become fully digital in their documentation and record keeping. HIMSS Analytic’s data suggests that less than 4% of hospitals today are even halfway toward achieving a true electronic health record and 0% have actually achieved it. Most hospitals are making progress towards this goal.
As they struggle with the decision to buy a particular software solution they sometimes believe the infrastructure design (cabling, network, data center, etc) is somehow related to, and dependent upon, their software purchasing decision. This could not be further from the truth.
A properly designed IT infrastructure should, and must, support any HIS software they might choose. The infrastructure is part of the building and very long lived. The software may change several times during the life of the cabling infrastructure.
Don’t let the IT staff delay the decision making process about the infrastructure because they haven’t decided on their HIS vendor yet. This will only delay the project and increase the cost.
Also, don’t assume the hospital IT staff really understands the technology infrastructure requirements of a modern hospital. See the discussion below about letting the IT guy design the new hospital.
A good example of this is PACS (Picture Archiving and Communications System). A PACS system is nothing more than software and some servers. The only impact PACS has on the building (other than eliminating the need for film development and those light table things on the wall) is some space in the data center for some servers and cabling (standard data and power) to any location where you might want the ability to view images. In fact a PACS viewer can be located anywhere there is a data outlet. The building design doesn’t care if the PACS system is Kodak, Fujitsu, Agfa, Cerner, or anything else for that matter. As an aside, should software really be part of the building construction budget?
Another key thing to understand is if you get the correct infrastructure (cabling, power, cooling, etc.) in place, most all the other technologies can easily be “bolted on” or added later without impacting the facility. Examples of this include patient entertainment systems, asset and staff tracking systems, etc. This is important to remember when you are prioritizing spending when the budget gets tight.
Don’t Let the “IT Guy” Design the New Hospital
Most hospital IT staffs are overworked and understaffed. They are tasked with keeping all existing equipment, networks, software and related technologies functioning on a day to day basis. Furthermore, hospitals are not known for investing in their staff resources in the form of education or training and development. Thus many hospital IT staff resources are often not in a position to understand or be knowledgeable about the latest technologies available.
Planning for major construction or a new hospital comes around once in a life cycle for most IT departments. However, because technology is not understood as well as other areas of healthcare management, the assumption is often the IT department “can make it happen.” A very wrong assumption!
Another thing to remember is many (but certainly not all) who carry the title “CIO” or “IT Director” in many community hospitals are ill equipped to advocate for the necessary IT infrastructure spending at the “C Suite” table and often lack the vision necessary to plan a modern healthcare facility. They tend to be very reactive in their behavior and are typically not proactive planners.
Add the fact that even the best IT people probably don’t have the necessary knowledge about the building design and construction process and you can begin to understand the problem.
Why is it that a hospital needs a program manager, an architect, a structural engineer, civil engineer, MEP engineer, landscape architect, signage and way finding consultant, a food service consultant, a CON consultant, an art consultant, a fund raising consultant, etc. and yet when it comes to an important issue such as IT planning, the IT guy will handle it? This is no different than saying the maintenance engineers should design the HVAC system or the power systems or the facility director should do the architecture.
Cell Phones are Now an Expected Utility
For most hospitals the days of banning cell phones are over, and nearly all hospitals today allow cell phone use. In fact the pendulum has swung so far that today most patients and physicians have come to not only expect, but demand cell phone service everywhere in the hospital. Why carry a text pager and a cell phone?
However, hospital buildings are great attenuators of wireless signals including cell phone signals. As a result cell phone reception in many parts of most hospitals is poor or non existent. This is driving many hospitals to install distributed antennae systems (DAS) to improve cell phone reception. These systems have the added benefit of enhancing a broad spectrum of wireless technology including wireless medical telemetry (WMTS), public safety radio, 802.11 and other wireless systems with improved coverage and signal strength.
Audio-Visual isn’t Just for PowerPoint Anymore
Healthcare has seen an explosion in the use of audio-visual technologies in recent years. In the healthcare industry, we have seen radiology images being distributed within the organization and across the world, the increased use of cameras for security, teaching, identification, and many other applications that in the past were done manually or not at all. Audio-visual technology has vastly improved the quality of information to clinicians resulting in better and more effective health decision making processes.
The operating room has seen the most change in this area and audio-visual technologies have dramatically improved surgical outcomes by enabling minimally invasive surgery techniques. Also the ability to remotely view and broadcast a surgery vastly improves training and education.
The use of electronic informational displays to improve workflow efficiency is also now widespread. So too is the use of audio-visual technologies for training and professional development.
Audio-visual technology is expensive. Proper budgeting and upfront planning is critical.
IT Budgeting – This Stuff is Expensive
This may be the most important lesson of all. Few project managers or architects know how to properly budget for the IT needs of a new hospital project. Surprisingly, this is also true of the hospital IT staff. The GC’s don’t know how to do it either.
With the most basic technology and communications infrastructure program running in excess of $15 per square foot and the total technology cost for a major addition or a new hospital easily doubling this figure, we are talking big money.
Sometimes the “construction project” is asked to bear all the IT costs including computers, printers, copiers, servers and software. One hospital’s policy is to even capitalize the IS labor required for implementation. If that is the case, the cost can be much more then $30 per square foot.
For example does the new addition require a new phone switch? What about the data center? Whose budget includes the network switches and other network electronics? Where are the patch cords included? What about AV technologies – a single integrated digital OR can run over $1,000,000 in AV alone. Who is covering the conduit and back boxes? Will the new security system require an upgrade or retrofit to the existing space? How about that asset tracking or patient entertainment system?
The biggest, most often repeated mistake we see in healthcare construction today is inadequate budget planning for technology and medical communications. There are certain things you just can’t cut out. Helping to prioritize the technology spending is critical. Budget surprises late in the project design cycle can be real trouble.
Some of the systems that are often forgotten during the budgeting phase include:
- DAS
- Televisions and TV mounting arms
- Mounting arms for the thin clients in the patient rooms and other points of care
- Servers needed to drive the thin clients
- Desktop PC’s and software licenses
- New network hardware
- Patch cords
Wireless Doesn’t Mean Less Wires
One of the very few areas in IT where the healthcare industry can claim to be a leader is that of wireless networking. Hospitals were very early adopters of wireless networking (802.11 or Wi-Fi) primarily due to the obsolescence of their facilities from a networking communications point of view. It was easier to add an 802.11 wireless network than it was to wire the old hospital for data connectivity. That was fine as long as the traffic on the 802.11 network was minimal. However, add wireless phones, start transferring PACS images, and add multiple users to the wireless network and you bring it to its knees in a hurry.
The point is that wireless is great but it will NEVER replace the wired connectivity in a hospital. The bandwidth demands are just too great. Today’s modern patient room requires robust wired connectivity, as many as 14 data outlets (not faceplates but outlets) is not unreasonable in many cases. For example, a 4 jack faceplate on each side of the headwall -- that’s 8 outlets. Another 2 jack faceplate in the family area, the charting area and at the TV and that’s another 6. You get the picture.
You Can’t Bolt Security on at the Last Minute
Security in a hospital has become a significant concern over the last several years, even in rural and other outlying areas. Good security does not come from adding cameras and access controls to a project during construction. Good security must be designed into the building from the beginning. Hiring a security contractor to design and install these systems during the construction phase just doesn’t work anymore.
Good security requires understanding the risks, the project’s environment, proper space planning, good policies and training, and only then should we start thinking about the bells and whistles (cameras, card readers, etc.). Security should be part of the discussion from the earliest schematic design discussions.
Also today’s modern security systems run on the IT network making close coordination with the IT staff critical to success.
Online, Real Time, All the Time
The bottom line is that IT systems in hospitals today are critical to providing clinical care. This is a huge change from just 5 or 6 years ago when the only thing really impacted by network or system downtime was the ability to send bills and for the administrators to communicate via email. Today if these systems are down the hospital can no longer provide medical care. Think about this fact and the implications to hospital design and construction.
As clinician’s become ever more dependent on IT to view images, communicate lab results, issue orders, document clinical information, generate a diagnosis, etc. it becomes a life critical business imperative that these systems be available “online, real time, all the time.”
Don Kinser, PE, is the chairman and CEO of EDI. He can be reached at dkinser@ediltd.com.
