Healthcare: Can technology fill the gap?

April 2020

Words by Katie Puckett

By 2050, there will be more than 1 billion people over 70. Who’s going to take care of us?

As the century progresses, the global population will become progressively older. In 2010, there were 350 million people older than 70, and 11.8 people of working age for each of them. By 2030, the ratio of workers to over-70s will have tumbled to 7.9, and by the end of the century, it will be just 3.4.[1]

The healthcare workforce is larger than at any time in history. In OECD countries, employment in health and social work has grown by 42% since 2000, to encompass one in ten jobs.[2]

But there is still a shortage. Today only half of all countries have enough healthcare workers to deliver quality services, and no country is on track to meet all of the World Health Organization’s health-related Sustainable Development Goals by 2030.[3] The ageing population and the rise in non-communicable diseases will generate demand for 40 million extra healthcare workers by 2030 — which would mean doubling the current workforce. Without action, the WHO warns that there will be a shortfall of 18 million healthcare workers, particularly in lower-income countries.[4]

“We do not have the capacity to meet growing demand. That means we have to do things very, very differently”

Suzanne MacCormick, WSP

The healthcare workers of the future are more likely to come from Africa than anywhere else. Only Africa is projected to have an old-age dependency ratio in double figures by the middle of this century, with just under 16 workers to older people, compared to 3.5 in Northern America and just 2.7 in Europe.[5]

Can technology fill the gap?

The last decade has seen a resurgence in health R&D, particularly in medical technology. Healthcare is second only to IT in research, with worldwide R&D spending reaching US$177bn in 2019.

The last ten years have seen strong growth in patents too. In the world’s top science and technology clusters, medtech is now the most frequent field of patenting. But this likely underestimates the actual level of innovation, notes the World Intellectual Property Organization, as health-related R&D is taking place in many other fields, including artificial intelligence.[6] Regulatory agencies such as the US Food and Drug Administration have approved record numbers of novel medical devices over the last five years, heralding an era of breakthroughs in material science, digital health and other technologies,[7] while venture capital is flooding into health start-ups.

New tools will diagnose problems, cure diseases, improve efficiency and disrupt business models. Genetics, stem cell research and 3D printing will enable more personalized treatments, while automation, data analytics and AI will underpin everything from robotic surgery and diagnosis-by-algorithm to patient monitoring and caregiver support. Wearables will prevent illness by flagging risk factors and nudging us towards healthier lifestyles.

Healthcare is one of the biggest targets for the big four tech companies, with Alphabet, Apple, Amazon and Microsoft all investing heavily in R&D, acquisitions and collaborations. Google has shown that its AI can detect diseases such as lung or breast cancer and acute kidney injury earlier and with greater accuracy than traditional methods. In a study with more than 400,000 participants, researchers at Stanford University found the Apple Watch reliably identified heart rate irregularities that were confirmed to be atrial fibrillation, a leading cause of stroke and hospitalization.

Smart thermometer company Kinsa has aggregated anonymized data from its network of devices and apps to create the US Health Weather Map, showing the level of flu-like symptoms — presumed to indicate COVID-19 — in different areas across the country.[8] Photo: Kinsa

“With new technology and service models, we’re increasingly able to provide a lot of care outside hospital,” says Mike Lovas, design director at Healthcare Human Factors in Toronto, a consultancy within Canada’s largest academic hospital network, UHN. “We’re looking at how we can help people be healthy or enable them to manage their conditions at home, setting up systems to monitor and keep them stable.”

In collaboration with cardiologist Dr Heather Ross, Lovas’ team helped design Medly, an app that monitors patients at risk of heart failure, the single most common reason for hospital admissions in Canada. Every morning, patients check in with their weight, blood pressure and symptoms, and receive feedback from Medly’s cloud-based algorithm — perhaps a warning about their salt intake or to increase their medication.

If they need more attention, a nurse will be alerted. The system has not removed the need for human intervention, but it has changed the number and types of role. “Over time, we’ve made the system smarter and we’ve increased the patient-to-nurse ratio — we now have 400 patients to one registered nurse. We don’t need a physician to field every clinical question.”

Lovas is now design director of the Smart Cancer Care initiative at Princess Margaret Cancer Centre, one of the world’s largest, which aims to reimagine the future of cancer care. Since the start of the COVID-19 pandemic, they have successfully virtualized around 75% of clinic visits. “We’re now exploring how we can deepen virtual care, so that it’s not just phone or video. We’re looking at nurse-led virtual clinics, asynchronous messaging, remote symptom tracking, and automated follow-up visits — the patient submits lab results, symptoms scores and questions, and the clinician reviews. If everything is okay and the patient doesn’t want to see the doctor, they just schedule the next follow-up in 6-12 months.”

4.6% of global carbon dioxide emissions are produced by the healthcare sector — higher than both aviation and shipping [13]

We also face new threats, the magnitude of which is still unknown

Epidemics

At the time of writing, more than 2.5 million cases of COVID-19 have been reported to the World Health Organization and more than 180,000 people have lost their lives. Epidemics are able to move faster and further than in the past, due to globalization, greater connectivity and denser cities. “A new HIV, a new Ebola, a new plague, a new influenza pandemic are not mere probabilities … The only major uncertainty is when they, or something equally lethal, will arrive,” the WHO said in 2018.[9] COVID-19 was first reported to the WHO on 31 December 2019 from Wuhan, China; within eight weeks, it had reached six out of seven continents.

Climate change

Climate change threatens food supplies, increases the risk of exposure to extreme weather and wildfires, creates favourable conditions for the transmission of disease, and exacerbates the effects of air pollution. “The life of every child born today will be profoundly affected by climate change,” wrote The Lancet in 2019. “Without accelerated intervention, this new era will come to define the health of people at every stage of their lives.” [10]

Air pollution

Outdoor air pollution causes 4.2 premature deaths annually.[11] By 2060, it is projected to prematurely kill 6-9 million people worldwide each year, and cost 1% of global GDP as a result of sick days, medical bills and reduced agricultural output.[12]

Male hand with pointed forefinger isolated on white. Leonardo da vinci style

What about the people?

Technology will support the healthcare workforce of the future, but it will not replace them.

Health is one of the least automatable sectors — according to management consultant McKinsey, only 36% of activities can be automated, predominantly data collection and processing.[14] Clinicians will still be needed to care for people, to interpret and contextualize sensitive information and to explain the choices available.

But as workplaces, today’s hospitals leave a lot to be desired, says Mike Lovas at Healthcare Human Factors. “Different types of work happen in a hospital — consulting with patients, doing physical examinations, preparing medication, communicating with colleagues, providing education — all with different demands. But hospitals typically have limited function. There’s a case room with a bed and a computer, and there’s the hallway. Clinicians flip fluidly between different contexts, but they often just do the work wherever they can find space. Hospitals, especially older ones, are not optimally designed for the variety of work that takes place there.”

“We can provide all this great technology, but the patient will always be a human. A human connection is part of the healing process”

Kevin Cassidy, WSP

Not having the right kinds of spaces means activities take longer, and increases the likelihood of mistakes. “When somebody’s carying out a high-risk task, like administering certain medications, they absolutely cannot be distracted,” says Lovas. “The physical design of spaces can go a long way in supporting patient safety, specifically in the way that we allow clinicians to focus on critical tasks.”

Clinicians can do the most good interacting with patients, but much of their time is often taken up with tasks elsewhere, or in moving between locations, especially in older facilities built for a different age. A 2018 survey used wearables and a sensor network to monitor contact time in a US intensive care ward, and found that nurses spent just 33% of their time in patient rooms, and physicians 15%.[15] So designers of new hospitals seek to devise more efficient, connected layouts. “We’re looking to reduce the amount of steps that someone has to take to do their job, and increase visibility so one person can monitor multiple activities,” says Jason Schroer, principal and director of health at HKS in Houston, Texas.

At the ProMedica Health Wellness Center in Ohio, HKS’s design reduced average walking distances by 36%, or one minute and 55 seconds per patient encounter, a difference ranging from 28 minutes to more than an hour each day.

This could extend to grouping services more logically, reflecting the way they are likely to be accessed, says Vivien Mak, director at P&T in Hong Kong. “If you’re an outpatient coming back for a follow-up, you might have to go through five departments to see a doctor, have an x-ray, or a blood sample taken, pay for your medicine and collect it, and these might be in different buildings. If all of these facilities could be combined or put on a platform that is multidisciplinary in terms of care, then the patient can come to a one-stop service centre.”

Part of the problem is that healthcare estates have typically been developed piecemeal over many decades. “There have probably been quite a number of changes and additions, but they weren’t done according to a masterplan,” says Mak. “New blocks were built wherever was available, and the allocation of functions may not relate to the original block that well.” For both new-builds and redevelopments, she says, a common approach is to group facilities for outpatients, in-patients and “hot zone” functions such as operating theatres and intensive care units (ICU), and allow more sustainable expansion. “It’s becoming very important to plan for the future of these zones, and how they connect with each other.”

“If a nurse spends 35% of their time walking to and from the medication room, and we can reduce that by half, that gives them more opportunity to care for patients”

Jason Schroer, HKS

It’s rarely possible to shut down a whole hospital once it’s running, so reforming the masterplan is a long-term endeavour. Mak is involved in two such projects at public hospitals in Hong Kong. “You need to devise a grand plan for the hospital to be redeveloped phase by phase over the coming decades. You need to identify, where you can, some space for decanting and then decide which block goes first.”

Above Moxi by Diligent Robotics is designed to automatically perform the nursing tasks that don’t involve interacting with patients, such as refreshing supplies
Moxi by Diligent Robotics is designed to automatically perform the nursing tasks that don’t involve interacting with patients, such as refreshing supplies. Photo: Diligent Robotics

Better logistics can also free up staff time. Hospitals are complex networks of supply chains for items that must be delivered without delay or contamination. Gunnar Linder, regional director at WSP in Sweden, says a central equipment store — shared between different operating theatres with just-in-time delivery — frees up clinical space, cuts walking distances and reduces overall equipment requirements.

In Hong Kong, there is also a move to separate elderly and acute care. Older people with complex conditions requiring long-term care will be looked after in specialized infirmary units, freeing up acute wards. “When you design an acute hospital for all services, you have to facilitate circulation and connections with operating theatres and ICUs. But most infirmary care patients don’t require those services, so it’s more efficient to look after them in another setting.”

Standardizing room and floor layouts could help to design out errors, she adds. This way, staff know automatically where to find the things they need: “No matter which floor staff move to, the logic is the same.” This applies to workflows too: “Say you always go through a certain procedure — you always greet the patient here, then move onto a certain function and so on — we devise a diagram that can be repeated across the hospital.”

Any workplace design requires the input of the users, but time-pressed nurses are not logistics specialists. Linder’s team has built a database of previous designs, “so they don’t have to start from scratch. We can map those rooms to maybe 90% accuracy at the beginning and then use their time and energy to take it from there.”

Lovas warns that “change fatigue” is very real in healthcare: “Frontline staff are used to old technology and siloed systems, they’re full-on in terms of workload, and especially in academic hospital settings, they’re constantly asked to do new things for different research studies. So there’s a huge hurdle to be overcome to introduce new systems, technology or models of care.”

Notes

[1] UNdata, World Population Prospects, 2019 Revision. Based on working age of 20-69 [2] Health at a Glance 2019, OECD [3] The Lancet [4] “UN Commission: New investments in global health workforce will create jobs and drive economic growth”, WHO, 20 September 2016 [5] UNdata, World Population Prospects, 2019 Revision. Based on working age of 20-69 [6] Global Innovation Index 2019, World Intellectual Property Organization [7] Food and Drug Administration, January 2019 [8] healthweather.us [9] WHO/IHM [10] The Lancet [11] WHO [12] The Economic Consequences of Climate Change, OECD, 2015 [13] The Lancet Countdown, 2019; CarbonBrief [14] A Future That Works, McKinsey Global Institute, 2017 [15] The American Journal of Medicine, Volume 131, Issue 8

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