The impact of medical technologies on the future of hospitals

During the next decade diseases requiring medical intervention will be much the same as those being treated today. The site of care may, however, be moved away from the community general hospital to a non-hospital site or to a higher order or specialty hospital at a distance.

With the applications of technological advances, procedures that once were performed in hospitals are now done in free standing facilities, accelerating a trend that began in the United States in the 1980s with the introduction of magnetic resonance imaging, fibreoptic endoscopes and arthroscopes, and ambulatory surgicentres. Just as the discovery and successful treatment of Helicobacter pylori for peptic ulcer replaced a commonly performed operation so new advances will eliminate the need for care once provided by hospitals, and hospitals will become places that treat conditions that cannot be treated in other settings.

Summary points

• Pharmaceuticals will replace some procedures and will decrease the need for admission to hospital, and newer vaccines will treat as well as prevent disease

• Minimally invasive surgery will reduce hospital stay and promote outpatient operations

• Sensors will change central laboratories and intensive care units of today

• Digitised images will be accessible to all clinicians

• Xenotransplantation from transgenic pigs is ever more likely

• Economics and superior outcomes will favour specialty hospitals

Pharmaceuticals

An abundance of new pharmaceuticals will alleviate a wide range of common diseases that account for a large proportion of patients currently admitted to hospital for inpatient care. New pharmaceuticals will reduce the incidence of atherosclerosis, coronary artery disease, and in particular stroke. Other pharmaceutical advances will promote the opening of stenotic arteries and the dissolution of acute thrombi. Biotechnology companies are developing products that will prevent, modify, or treat a variety of cancers—breast cancer being one of the first treated.¹,² How significantly pharmaceuticals will affect infectious diseases, and therefore hospitals, is uncertain. In the future it will be necessary to consider two groups of infectious diseases—those that are resistant to antibiotics, a problem increasing inside as well as outside hospitals, and new or re-emerging diseases that require inpatient care.³ The latter group comprises the growing number of common chronic conditions that are caused by an indolent infection—for example, peptic ulcer and cancer of the cervix. Although the relation is far less certain, evidence is accumulating that infection has a role in the cause and progression of arteriosclerosis, diabetes, and cancers including hepatoma, gastric carcinoma, and lymphoma.⁴

Vaccines

The potential impact of a new generation of preventive and therapeutic vaccines is not generally recognised, even among health professionals.⁵ An effective vaccine for hepatitis C will eliminate chronic infection among high risk groups and a major cause of hepatoma and liver failure requiring liver transplantation. A vaccine for the human papillomavirus can prevent most cancers of the cervix. Therapeutic vaccines for cancer are being used today, and their effectiveness will improve. Add vaccines for type 1 diabetes and HIV and the implications of vaccines for hospitals may become significant.

Minimally invasive surgery

Minimally invasive surgery has transformed many surgical procedures. Heart surgery performed robotically through pencil sized openings in the chest is one such operation. The most common operation in cardiac surgery—coronary artery bypass grafting—can be done robotically, the surgeon performing the procedure while seated at a console near the operating table.⁶ The same technology is being applied in operations on other parts of the body. High tech surgery will therefore become the norm for many operations, and the staff, space requirements, and equipment for the procedures will be as different as the technology itself.

Endovascular surgery has emerged on a parallel but different course. Today endovascular surgeons repair intracranial aneurysms,⁷ effectively exclude abdominal aortic aneurysms, and widen or open narrowed arteries throughout the body. Coronary angioplasty will continue to be the most widely practised endovascular procedure, and experts predict that pharmaceutical, surgical, or preventive advances will not materially change its use in the management of coronary heart disease. In fact with the imminent availability of angiogenesis factors, myocardial gene therapy, and stem cell technologies—all of which can be delivered with endovascular techniques—endovascular cardiology may expand. Improvements in stent design and effective measures to inhibit restenosis will further broaden the applicability of endovascular approaches. The implications for hospitals concern the reduced demand for cardiac surgery and the expansion of facilities and staff to accommodate the movement of patients from the operating room to the cardiac catheter laboratory.

The least invasive of all minimally invasive surgical technologies is radiosurgery. Initially thought to be applicable to only a small proportion of specific brain tumours and a minority of congenital vascular malformations in the brain, radiosurgery is now being used to treat many brain tumours and cerebral vascular malformations as well as Parkinson's disease, epilepsy, and trigeminal neuralgia. Radiosurgery has replaced conventional neurosurgical procedures for all these conditions. Patients will be treated in a special facility within the department of radiation therapy thus moving the point of treatment to a different site within the hospital and decreasing hospital stay for each of these indications, and in the process changing two units of the hospital.

Robotics

Since the introduction of robots to manufacturing they have become increasingly sophisticated, and with the addition of sensors and voice recognition robots have acquired a type of intelligence making them almost humanoid. Expect robots to be deployed in hospitals over the next decade, running central supply services, filling requests and orders in the pharmacy, and carrying out a range of tasks.⁸

Sensors

By the end of this decade beds and tables in the intensive care unit, private hospital rooms, operating rooms, and selected endoscopic units will be equipped with sensors linked to nearby and remote monitors. Inpatients may be implanted with tiny sensors as part of the admission process, and throughout the patient's hospital stay the chip will provide values instantaneously for the 40 or so laboratory tests that constitute 90% of a hospital laboratory's volume, thus changing the role of the central laboratory.

Hospital gowns or undershirts with embedded sensors may serve as continuous monitors for vital signs for ambulatory patients. Expect the next generation of transportable intensive care beds, such as the life support for trauma and transport unit (LSTAT, Northrop Grumman), to remove critically ill patients from centralised intensive care units, where the main complication is cross infection. Most patients will bypass the central intensive care unit and receive care—for example, for cardiac surgery or neurosurgery—on specialty aggregated units. The same bed will be used in the operating room, the recovery area, and the satellite specialty intensive care unit.

Xenotransplantation

Several centres in the United States and Europe have been working with transgenic pigs, and in these laboratories, where human genes are introduced into pigs to produce transplantable organs, the mood is more optimistic than at any time in the past.⁹ Imutran, a British biotechnology firm, is currently testing the safety of pig to human transplants, and guidelines for xenotransplantation are being developed in anticipation of clinical trials. Initially, xenotransplants will be used as a temporary measure for patients awaiting a human organ. The possibility of large scale xenotransplantation by the end of the next decade—maybe sooner—cannot be ignored, and well informed investigators predict a high likelihood of success for xenotransplantation. If xenotransplants become widely available the impact on hospitals will be enormous, as will the benefit for the thousands of patients awaiting a donor organ.

Imaging

Images in digital format can be transported electronically, sorted, read, saved in an archive, retrieved, and called up in any area within a local or extended network, including physicians' offices. The picture archiving and communication system (PACS) offers increased efficiency with economic advantages—fewer clerks and typists, no darkroom technicians, no off-site film storage, and no costs for film or chemicals. These cost savings will, however, be offset by the need for workstations, networks, software, computers in wards and physicians' and specialists' offices, and retraining costs.¹⁰ The integration of radiology and hospital information systems and picture archiving and communication systems will contribute to the development of an electronic medical record that will become the entry point for physicians, who can gain access to images and their interpretation through a personal computer. The availability of the same image in various places simultaneously will promote teleradiology consultation, remote interpretation, educational conferencing, and other new means of interactive exchange through open links.

Specialty hospitals in the future

Regionalisation of organ system based or specialty based medical technologies is an old concept in much of the world. Regional centres of excellence have long existed, but in the United States—because of powerful economic incentives—every hospital has wanted to offer almost every procedure, from open heart surgery to renal transplantation. Several factors will compel regionalisation where it does not exist today and will broaden the influence of the concept where it exists already. Principal among thefactors driving regionalisation of specialty care are: economic forces because of the high cost of many new technologies; public accessibility of information indicating the superiority of outcomes on the basis of the physician's experience and volume of cases treated; and a better educated public because of their use of health related information provided by printed and electronic media. For complex surgical and interventional procedures a large volume of cases is required to develop skilled staff, standardised processes, high levels of efficiency, and optimal outcomes. For example, for any highly technical procedure the best outcomes are achieved by surgeons and interventionalists who deal with large numbers of cases in hospitals that also manage large numbers of the same kinds of cases. There is a steep learning curve for procedures that entail minimally invasive technologies, complex image guided systems, robotic enhancement, and coordination as part of a skilled team, and once proficiency is attained a continued high case load is required for maintenance of those skills. General hospitals will treat those conditions that have less exacting requirements for equipment and training, and many will continue to support some level of tertiary care. Some general hospitals will always treat cases requiring tertiary care services particularly in regions with low population densities. Wherever resources and the volume of cases permit, however, complex specialty procedures of high risk will be shifted to hospitals that are, or will become, centres of excellence.

The hospital of tomorrow

We are entering a decade of major changes in medical technologies affecting health care and especially hospitals. Some technologies will influence the incidence of diseases that today constitute an important proportion of hospital admissions. Others will require changes in the physical plant itself because today's hospital cannot accommodate the changes with only minor alterations. Large hospitals will be affected disproportionately more than smaller hospitals, but no hospital will be spared. In the future new hospitals will be built with a greater flexibility of configuration than in the past, architects realising that further changes are inevitable. Will tomorrow's hospital be modular? Quite possibly.

Figure.

INTEGRATED MEDICAL SYSTEMS INC/NORTHRUPP GRUMMAN CORP

Life support for trauma and transport unit (LSTAT) with model

Figure.

INTEGRATED MEDICAL SYSTEMS/NORTHRUPP GRUMMAN CORP

LSTAT in use