Future Perfect: Trends Shaping Healthcare Architecture

When most of us think about the future of medicine, architecture is not the first thing that comes to mind. We think of advances in technology, enabling better imaging techniques, robotic surgery, and advances in medical research, enabling genetic engineering of which miracles are now expected.

We think, too, of the current healthcare crisis in the developing countries: the inescapable reality that many people do not have access to good basic medical care, let alone technological wonders now in existence and yet to emerge.

The great nineteenth-century dramatist, Henryk Ibsen, wrote two plays that we would like to mention. An Enemy of the People and The Master Builder. The hero of one is a physician, of the other, an architect. Both men find themselves faced with similar tasks: to diagnose and heal the ills of their community and society. Physician or architect, both promote the health of humanity and civilisation.

This concept drives our practice as healthcare architects. But it is more than a talisman or metaphor. It is a reality. If there is a single trend that is definitive in shaping the future of hospital and healthcare facility design, it is the emergence of architects and designers as full partners in planning and delivering medical care.

Three mega-trends will shape the future of medicine in the next 100 years.

1. Medicine will address the causes of disease, digging to the roots – or, more correctly, the seeds – of life itself, engineering human genes, chromosomes and molecules in order to eliminate rather than attempt to cure disease.
2. For those diseases and disorders that cannot be engineered out of existence and in the case of injury and accident, non-invasive treatments (especially drug therapies) and minimally invasive procedures will extensively replace surgery. Such procedures will increasingly be performed at home or in outpatient settings rather than in hospitals.
3. Genetic engineering, insofar as it succeeds, will be the most cost-effective way of dealing with disease. Not to plug and patch, but prevent. What cannot be prevented, however, its treatment will be judged on a cost-versus-benefit basis.

These are sobering trends, particularly the first and third. Genetic engineering is the centre of much controversy about the potentially disastrous consequences of meddling with nature. It raises the question is human genetic engineering morally correct? These are valid and highly disturbing questions. On the other hand, we are familiar with the consequences of the failure to eliminate disease – high cost medical care of questionable effectiveness. A moral dilemma, if ever there was one.

Scarcely less disquieting in its implications is the third mega-trend
– healthcare on a cost-versus-benefit equation. The physician’s Hippocratic Oath prevents them from putting any kind of price on human life. Until some time back, to do “everything possible” for a patient cost very little more than to do nothing at all, simply because there was not much that could be done.

Hippocrates treating a patient

To be sure, the ambition to do all one could to save a life is a noble one. In the past, it was also economically feasible. Today, however, there is much, much more that can be done for any given patient – and each of these procedures, drugs and interventions comes with a price tag, which the individual and ultimately society must pay. Indiscriminately paying “for it all” has already become crippling to society, and insurance providers and government agencies are now acknowledging that it is not merely crippling, but fatal.

Diagnosis Related Groups (DRGs) are already expressions of judgement about the effectiveness of procedures. Insurance providers and government agencies are saying that they will pay for procedures proven to be effective, but they will not pay for unproven or marginally effective treatments. Such cost-versus-benefit judgements will play a greater role in the delivery of healthcare, no matter who is paying for the treatment. No longer will healthcare providers have sacrosanct license to do “whatever is necessary” in each and every case.

The cost-versus-benefit goes beyond rupees and paise. Healthcare consumers will increasingly weigh the prospective benefit of a given treatment against the quality of life they may expect as a result of it. It is not only likely that more patients will opt out of treatments that prolong misery in order to merely prolong basic life processes, but that life termination will become a viable medical option.

What will be the new roles for Healthcare Architects in this radically changing future?

1. They will probably be asked to create fewer hospitals and more ambulatory facilities, including freestanding clinics, medical office buildings, and specialised freestanding diagnostic centers. In addition, we may see an increased demand for healthcare facilities on the retail model – medical malls, possibly in landscaped settings.
2. One possible scenario is a system consisting of speciality hospital facilities – maybe on the retail model – and strategically placed regional complexes: very large, very comprehensive hospitals in which specialised facilities and specialised practitioners are concentrated. Remote monitoring telemetry, and sophisticated data transmission will link the local speciality hospital to the more distant comprehensive facility, making a trip there unnecessary.
3. There may be new opportunities in healthcare hotels and healthcare communities. Healthcare hotels would be places for convalescence and supervised care – a hybrid cross between hotel, spa and hospital. Healthcare communities are another likely direction, as a large percentage of the population ages. Planned communities focused on wellness, and providing various levels of assisted living may largely take the place of hospitals, skilled nursing facilities and retirement villages.
4. Architects will be called in on planning processes earlier, they will be asked to contribute a very broad range of expertise, and they will be active during the entire lifespan of the building. In a sense, architects will serve as caregivers, members of the patient-care team.
5. The present cutting edge and the future of healthcare architecture are being driven by economics, as well as by two imperatives usually assumed to be mutually exclusive: high technology and high humanity. We have discussed that these two need to find common ground so that more technology can lead to a higher degree of humanity in healthcare. But still they lead us to a question that penetrates to the heart of the future of hospital and healthcare facility design. Can we design “healing” buildings? This would be the central focus of the future of healthcare facility design.

The drive towards market reform in the U.S. health care delivery system is likely to result in the eventual replacement of most individual health care providers with integrated health networks. With the entry of corporate houses into the field of health care delivery in India too, we can see the beginning of this future trend. This change will dramatically alter the political, economic and social setting in which health care services will be provided. This integrated health care environment will probably be characterised by:

• Increased incentives for cost containment and penalties for spending that does not result in overall savings
• More paying patients, as more people who are presently uninsured gain access to the health care system
• Regional and community based integrated health networks, less duplication of services, and creation of centers of excellence
• The extensive growth of ambulatory care services dispersed throughout a community, with inpatient services focusing on patients with greater acuity than in the past
• The increased importance of information management, outcomes analysis, and communications systems
• The proliferation of gatekeeper systems in which primary care physicians monitor referrals to specialised services
• Managed care and other capitated payment system
• An emphasis on disease and injury prevention

We healthcare architects need to practice medicine through competent and caring design. On the shingle we hang out we need to write: Healthcare Architect M.D. This is the way to our Future Perfect.

Sources: New Directions in Hospital and Healthcare Facility Design – Miller & Swensson The Architecture of Imaging by Bill Rostenburg, AIA – American Hospital Publishing

Technology and the Future of Medicine – Bertalan Meskó,MD,Ph.D.

The Future of Medicine – Harvard Medical School

The Future of Medicine – Cambridge University

Is This the Future of Health? – The Economist

The Future of Medicine | Aaron Ciechanover