Medical Research and its Impact on Healthcare Design - the ...

<strong>Medical</strong> <strong>Research</strong> <strong>and</strong> <strong>its</strong> <strong>Impact</strong> onHealthcare DesignHåkan Eriksson, Ph.D.Throughout the developed world differenthealth care systems are being challenged <strong>and</strong> undergoa turbulent period of intensive changes<strong>and</strong> development. The definition of a “hospital”is not obvious any more. We are graduallymoving from traditional hospital-based healthcaresystems to e-health. These changes are drivenby many factors e. g.:Socio-economic factors• Rising costs for health care – “the tyranny ofthe bottom line”• Demographic changes (increased number ofelderly; increased average length of life; multiculturalsociety; urbanisation <strong>and</strong> mobility)• Patient empowerment – knowing more, dem<strong>and</strong>ingmore“Changes in lifestyle” factors• The way we live (more one-person households;changes in indoor environment; fashiontrends (piercing, tattoos)• The way we eat (more prefabricated fast food;functional food)• The way we work (increased mobility; specialization;teamwork; processes)• The way we interact (mobile phones; e-mail;Internet; increased travelling)Political factors• Globalisation – disintegration of the nationalstate• Increased competition• Increased consumer influence• Environmental issues• More complicated infrastructure• but also Barriers of globalisation (new regulations;no acceptance of e-signatures; use oflocal names for drugs)… but perhaps mostly by the force entailed withthe rapid development of the medical research<strong>and</strong> information-communication technologies.The scientific advances in medicine havebrought about new diagnostic <strong>and</strong> therapeuticmethods based on new <strong>and</strong> partly different technologicalprinciples. Some of the most fundamentalinnovations have been made possible bythe “molecular revolution”, ushered in with thediscovery of recombinant DNA techniques <strong>and</strong>the break through in immunology (gene therapy;new types of vaccines; individually de signeddrugs; prevention based on molecular geneticsHåkan Eriksson, MD, Ph.D.Håkan Eriksson is professor of reproductive en do crinologyat the Karolinska Institutet <strong>and</strong> Chair man of thedepartment of Woman <strong>and</strong> Child Health at KI. He wasearlier the scien ti fic secretary of the Swedish <strong>Medical</strong>Re search Coun cil during 1978–1995 <strong>and</strong> the sec re taryof the Swedish Government Scientific Advisory Boardduring 1991–1994. He is pre sent ly coor dinator of a nationalR&D programme related to Information Technologyin Health Care. He has published approximately 120scientific articles <strong>and</strong> reviews involving pri ma rily studieson ster oid hormone me ta bo lism <strong>and</strong> action, hormonereceptors, calcium regulation <strong>and</strong> developmentof biomedical me thods. He has written articles <strong>and</strong>given talks regarding me di cal research <strong>and</strong> <strong>its</strong> impacton future Health Care systems. One of his most importantin te rests is the process of trans fe rr ing the results ofexperimental re search into clinical use ful ness.39

MEDICAL RESEARCH AND ITS IMPACT ON HEALTHCARE DESIGNfects. Some new methods based on cell biological<strong>and</strong> immunological basic science can alsobe expected to be used in clinical trials within aclose future.• Surgery. No decrease can be seen. The reasonsfor this is mainly that the large groupsof cancer in the ventricle, intestine <strong>and</strong> lungwill be treated similarly as 30 years ago <strong>and</strong> nosignificant therapeutic progress is at sight.• Radiation. A promising development of proton-radiationtherapy is taking place.• Cytotoxic drugs. The research studying thecellular factors of importance for the sensitivityof the drug is progressing rapidly. The resultsof this will make it possible to individualisetherapy at different tumour conditions,which will give better therapeutic results <strong>and</strong>fewer side effects.• Antibody therapy. The development of methodsto interfere with adhesion moleculeson the surface of the cancer cell will make itpossible to create drugs that will slow downthe progress of metastasis.• Autologue <strong>and</strong> analogue bone-marrow transplantation.In combination with cytotoxicdrugs this technique will be used for treatmentof tumours which can’t be cured today,e.g. malignant melanomas <strong>and</strong> solid tumourssuch as cancer of the colon <strong>and</strong> breast cancer.• Gene therapy. Large investments are made todevelop this technique for clinical purposes.It will be used on the one h<strong>and</strong> to replacea defect gene which will cause cancer, <strong>and</strong>on the other to modulate the expressing ofonco-genes <strong>and</strong> supressor genes. The latterform of therapy means a new strategy forcancer prevention <strong>and</strong> treatment. Anotherpromising form of therapy involves blockingof the an gio genesis.• Substantial improvements in the therapy ofdifferent forms of cancer in children; cancerin the lymphatic system, testis cancer <strong>and</strong> cancerof the urinary bladder.The new methods of tumour therapy willin the future have a profound impact on thestructural changes of the systems for the care<strong>and</strong> nursing of patients suffering from cancer.Therapy for diseases in the heart <strong>and</strong> bloodvesselsFundamental changes are taking place with regardto the treatment of different circulatorydisorders. The new therapeutic methods willresult in fewer inpatients at the hospitals <strong>and</strong>a better quality of life for a larger number ofpatients. Some trends are summarised below.• Surgery of the heart <strong>and</strong> blood vessels. Newless invasive technologies are developed.The “BIG” open surgery in the thorax <strong>and</strong>the brain will gradually be replaced by “catheter-based”techniques including PTCAin coronary vessels <strong>and</strong> introduction of“stents” in narrow vessels.• Technologies for revascularisation will beimproved (stents; ultrasound; laser, highspeeddrills). Also more serious damages ofthe vessel or long-lasting occlusions will betreatable. Transplantation of endotheliumwill be used.• Treatment of heart failure. A rapid developmentof new types of drugs is taking place(e.g. ACE inhibitors; peptide hormones).These new drugs will reduce the number ofin patients.• Treatment of stroke. The future will see less“classical” rehabilitation <strong>and</strong> more early, aggressivetreatment with e.g. TPA <strong>and</strong> streptokinaseafter thrombosis <strong>and</strong> drugs thatprevent the progress <strong>and</strong> expansion of thetissue damage after a haemorrhage. Acuteneuroprotective treatment will include theuse of cal cium-channel antagonists; GABAantagonists <strong>and</strong> antagonists against glutamate.• Methods to prolong the survival time forcells that have been exposed to hypoxia inthe brain or the myocardium will be develo-43

HEALTH MEDICAL FACILITY RESEARCH AND ITS IMPACT ON HEALTHCARE DESIGNped. This will create possibilities for reconstructivesurgery or other invasive techniquesto restore circulation before the damage becomesirreversible.• Drugs with improved specificity <strong>and</strong> selectivity(receptor blockers) produced by biotechnologywill make it possible to more efficientlytreat several conditions without anyside effects e.g. heart failure, arrhythmias, hypertonia<strong>and</strong> hyperlipidaemia.Transplantation as therapeutic methodsThe immunological research has resulted in newdrugs which counteract the rejection/reactionduring transplantation. Furthermore, it has createdconditions which will make heterologousorgan transplantation possible. Thus, the indicationsfor organ transplantation as a therapeuticmethod will be broadened <strong>and</strong> the dem<strong>and</strong>sfor surgical <strong>and</strong> nursing capacity increased. Thepresent situation can be summarised as follows:• Kidney, liver, heart, lungs <strong>and</strong> pancreas aretransplanted practically on a routine basis atdifferent centres specialising in transplantation• Transplantation of the intestine is still at aninitial stage• Great efforts are made to develop methodswhich will make it possible to use animalsas organ donors (xenotransplantation), particularlythe pig. Furthermore, extensiveresearch is carried out in order to solve theproblems connected to the rejection of insulin-producingcells from pig pancreas.• Transplantation of nerve cells (adrenal medullarcells <strong>and</strong> cells from brains of foetuses) isused in clinical trials to cure e. g. Parkinsons,Alzheimer, diabetes, epilepsy, damages of thespinal cord etc.Surgical therapy – consequences of thescientific revolution• “Classical” general surgery (ventricle, gallbladder, intestines etc.) will decrease, partlybecause of the development of new drugs<strong>and</strong> partly because of the introduction ofnew technologies (laparascopy). The remainingpart will primarily consist of cancer surgery,trauma surgery <strong>and</strong> reconstructive surgery.This will result in a reduced number ofin patients.• Emergency surgery will decrease <strong>and</strong> be concentratedto fewer hospitals. This will meanthe closing of smaller surgical clinics or turningthem into elective un<strong>its</strong>. Fewer <strong>and</strong> largerhigh-technology un<strong>its</strong> with high emergencycompetence will be formed. These structuralchanges will be most pronounced in thedensely populated areas whereas the thinlypopulated areas will be changed less.• Orthopaedic surgery. This will increase becauseof the rapid development of new materialsfor prosthesis <strong>and</strong> new drugs, whichwill speed up the healing process of fractures<strong>and</strong> damages of the soft tissues. It is possiblethat cell transplantation will be a new methodto treat damage of cartilage <strong>and</strong> bone. Improvedmethods to prevent <strong>and</strong> treat osteoporosiswill be used.• Laparascopic surgery will be used on widenedindications. The results of the methodwill be improved which will bring about amore extensive use of this technique.• Laser surgery will increase e.g. within gynaecology(early cancer in the cervix, vagina orlabia); urology (tumours of the urinary bladder,especially condyloma); otorhinolaryngology(cancer of the vocal cords <strong>and</strong> certaincases of cancer of the pharynx <strong>and</strong> larynx);<strong>and</strong> surgery of the coronary vessels.Therapy in psychiatric disordersConcerning therapy of psychiatric disordersthe development is mostly concentrated to a refinementof the psychopharmacological drugsthat are used today. Increased knowledge of thetransmission systems in the brain <strong>and</strong> the mode44 (IADH) International Academy for Design <strong>and</strong> Health

MEDICAL RESEARCH AND ITS IMPACT ON HEALTHCARE DESIGNof action of different drugs will make it possibleto improve the therapeutic precision <strong>and</strong>efficiency.• Selective drugs (serotonin inhibitors) withminimal side effects have been introduced<strong>and</strong> will be improved.• New drugs are being designed which will affectthe serotonin system according to a differentmechanism of action. These drugs willalso be effective against so called “therapyresistant”conditions.• The mode of action of lithium will be solvedwhich will create a basis for the developmentof new substances with less toxicity.• Development of more selective drugs withfewer side effects for the treatment of schizophrenia.• New methods for the optimisation of thedose of neuroleptica based on PET studiesof dopamine-receptor localisation.• A breakthrough in the underst<strong>and</strong>ing of thepathogenesis of schizophrenia can be expected.Therapy in the future – some speculations• Production of new types of drugs <strong>and</strong> vaccinesusing biotechnology. E.g. TPA producedby biotechnological methods will be usedin treatment of thrombosis in the brain <strong>and</strong>heart (acute myocardial infarction) <strong>and</strong> erythropoietinat anaemia caused by renal disorders.The genes coding for most of thelymphocytes have been sequenced which willmake recombinant substances available fortherapeutic use.• Gene therapy will be possible for monogeneticdiseases like Duchenne’s muscular dystrophy,using adenovirus vectors.• The etiological mechanisms behind the originof immunologicalinflammatory diseases likediabetes type 1, multiple sclerosis, rheumatoidarthritis will be solved <strong>and</strong> make preventionpossible.• HIV <strong>and</strong> AIDS treatment will be improvedby the introduction of new drugs. It is howeverdoubtful whether it will be possible tocreate a vaccine against HIV.• Vaccines against malaria, cholera <strong>and</strong> ordinarycold will be developed.Healthcare developmentThe development in the healthcare organisationis directed towards a process-oriented systemwhich honour keywords such as “patient orientation”,“knowledge navigation”, “coordination/feedback”<strong>and</strong> “benchmarking” <strong>and</strong> whichforms a logistic chain from “Social security system”– “Pre vention care” – “Primary medicalcare” – “Diag nostics” – “Therapeutics” – Rehabilita tion” – “Work/retirement” to “Follow-upmeasures” <strong>and</strong> includes patient-centred hospitals.The evolution can be illustrated as followsTodayFragmented servicesTreating illnessesAcute, inpatient careInstitutional measuresPerceived qualityIndividual IT systemsTomorrowContinuum of careManaging healthPreventive/primarycareCommunity measuresOutcome measures,report cardsIntegrated IT networksThis shift will most likely lead to a partial disintegrationof the omnipotent “Mega-institutions”,which try to cover everything in the medicalarea, <strong>and</strong> the formation of smaller customized<strong>and</strong> specialized un<strong>its</strong> which will collaborate inan integrated network, much based on moderninformation-communication technologies. Thehealth care system will gradually move from an“information hierarchy” to an “informationhyperarchy”. We will see the development ofa health network which integrates the informationflow related to the individual patient in thefollowing way.In this way it will be possible to integrate the45

HEALTH MEDICAL FACILITY RESEARCH AND ITS IMPACT ON HEALTH CARE DESIGNHealthcare system <strong>and</strong> information technology.different components of the healthcare systemfrom a patient perspective i.e.• Rapid <strong>and</strong> easy access to primary care• Services close to home• Access to specialist consultants• <strong>Medical</strong> records available at point of service• Collaboration <strong>and</strong> consultation among careproviders• Coordination of care• Clinical process improvement• Continuous quality assessment of care• Easy access to medical information.Since these changes will have a fundamentalimpact on the way healthcare professionals willwork together <strong>and</strong> with the patient, they willalso strongly influence the dem<strong>and</strong>s on the architecturaldesign of hospitals. Several serviceun<strong>its</strong> which today constitute physical parts ofthe hospi tal building will in the future be localizedoutside the hospital <strong>and</strong> instead be accessedvia IT networks. The figure below illustrates aposs ible future scenario in a hospital ward.All information regarding each individualpatient can displayed on a “patient navigator”connected to a wireless bedside informationsystem which can access databases in differentservice disci plines such as clinical physiology,laboratory medicine, image-processing center<strong>and</strong> pharmacy. Furthermore, the doctor canconsult both specialists via telemedicine <strong>and</strong>external health-status assessment databasesonline. After examination of <strong>and</strong> conversationwith the patient, all anamnestic statements, ordereddiagnostic tests <strong>and</strong> prescribed drugs arerecorded in the patient’s electronic record in thecentral medical record data base via the patientnavigator. This database can then be accessedby duly qualified personnel in e.g. the primarycare center to which the patient is affiliated.Thus the prerequisites for a development of“patient-centred care” are here <strong>and</strong> several keyfactors drive this evolution.46 (IADH) International Academy for Design <strong>and</strong> Health

MEDICAL RESEARCH AND ITS IMPACT ON HEALTHCARE DESIGNClinical physiologycenterImage-processingcenterLaboratorycenterPatient navigatorHealth-statusassessmentEBM databaseWireless bedsidesystemPharmacyConsultantspecialistElectronic medical recordTelemedicineconsultantAll information regarding each patient could displayed on a patientnavigator.• The underst<strong>and</strong>ing of genetic predisposition.This will make it possible to predict healthrisks for individuals by establishing links betweendefect genes <strong>and</strong> specific diseases. Furthermore it will serve as the basis for individualizeddrug treatment.• More readily available information. Throughthe Internet a whole new world of “Healthportals” will be accessible. These will be anythingfrom general health sites with medical<strong>and</strong> health news to highly specialized diseasespecific sites aiming at selective groups of patients.• More active <strong>and</strong> informed consumers. Thepatient educates her-/himself via chat groups<strong>and</strong> active patient groups on the Internet <strong>and</strong>via high-quality TV production in specificeducational channels.• Increasing responsibility of consumers. Thepatient will take active part in the diagnosticprocess e.g. by using “home diagnostics”.Visions of the future for the structure of thehealthcare systemIn a shorter perspective than 5 years it is not likelythat the medical research <strong>and</strong> developmentwill have any greater impact on the structure <strong>and</strong>function of hospitals <strong>and</strong> the health-care systemthan the one which is the result of already partlyimplemented, established new technologies asdescribed above. The fast development in prevention,diagnostics, therapeutics <strong>and</strong> communicationtechnologies will, however, create conditionsfor a society where most of the healthcarecan be h<strong>and</strong>led locally <strong>and</strong> close to the patientregardless where you live. The need for largehospitals will be reduced. The “hospital-free”society is coming closer. To bring this visiona step further let us first look on the presentstructure of the Swedish healthcare system. Inthat you can identify five distinct organisationallevels. Three of these levels include different-sizedhospitals, each with <strong>its</strong> own emergency ward<strong>and</strong> surgical department, which h<strong>and</strong>les similar47

HEALTH MEDICAL FACILITY RESEARCH AND ITS IMPACT ON HEALTHCARE DESIGNtypes of medical disorders. This means e.g. thatsmall numbers of difficult <strong>and</strong> advanced surgicaloperations are performed at a large numberof smaller hospitals on the municipal level bysurgeons with limited experience of that kindof surgery <strong>and</strong> that high-technology diagnostic<strong>and</strong> therapeutic techniques are introduced athigh costs in hospitals where they will be usedrarely by inexperienced personal.In order to get a high quality in the utilisationof these new <strong>and</strong> advanced technologiesthey must be concentrated to larger centres ofexperts at the regional-/university-hospital level,where a large number of diagnostic examinationsare performed <strong>and</strong> where R&D is a partof the daily use of these technologies. To theseexpert centres are concentrated diagnostic techniquesrequiring heavy, expensive high-technologyequipment <strong>and</strong> a cadre of specially-trainedphysicians <strong>and</strong> nurses <strong>and</strong> therapeutic methodsinvolving large, complicated operations <strong>and</strong>“aggressive” treatments. Since the classical borderlinesbetween different diagnostic laboratorydisciplines are gradually being more <strong>and</strong> moreunsharp, conditions are created for diagnosticcentres where radiology, clinical chemistry, histopathology,clinical physiology <strong>and</strong> clinical microbiologycan be integrated. These hospitalsshould in turn serve as nodes in an integratednetwork of different hospitals, primary- carecentres <strong>and</strong> nursing institutions which are localisedclose to the patients as outlined in the figurebelow.By doing this problems with investments innew expensive equipment <strong>and</strong> personal competence,can be h<strong>and</strong>led in a more cost-effectiveway.The new possibilities to transfer largeamounts of qualified information over longdistances <strong>and</strong> analyse <strong>and</strong> store it on other placesthan where it was generated will have a greatimpact on the future structure of the healthcareorganisation, since it will make it possibleto move the desirable diagnostic <strong>and</strong> therapeuticcompetence to the patient instead of viceversa.ConclusionsThus, the scientific achievements in medicine<strong>and</strong> information technologies have created conditionsfor a new healthcare structure with:48 (IADH) International Academy for Design <strong>and</strong> Health