The digital hospital
WHITE PAPER
The real-time healthcare information environment
Introduction
Peter Drucker once described the hospital as “— altogether the most complex human organisation ever devised …” (Drucker, 2002) based on the complexity of professional interactions, organisational objectives and where key financial decisions are not taken by management but medical professionals aiming to deliver the best possible patient care. The hospital is also the knowledge hub of the healthcare industry, a place where new medical professionals are trained and often a comprehensive research site and the place of last resort for patients with severe medical conditions.
From a functional perspective the hospital acts as a specialised hotel, catering to needs of admitted patients, specialised units where output is largely based on process flows, such as diagnostics, and treatment facilities with highly advanced technologies including robotics and mobility, where services are often individually tailored.
From an IT perspective it contains everything from structured data to potentially extremely large datasets produced by modern Genomic sequencing. The diagnostic functions of a hospital have the sole purpose of generating information for decision making, often absorbing 10%-15% of a hospital’s budget.
Stabell et al (Stabell, 1998) offer a theoretical framework that helps to understand the value creation of hospitals in their 1998 paper on “Value Configurations”. The hospital generates value through all the proposed “Value Configurations”, and participates in the broader healthcare eco-system, described by Stabell and Fjeldstad as “Value Networks”. To effectively support the different “configurations” IT must be lean and flexible.
For a hospital to work effectively it is critically important to manage information well and apply an architectural approach to its application of IT. Yet, hospitals, as most of the healthcare industry, have been slow to adopt information technologies. Only a small percentage of hospitals have achieved a high level of maturity in their adoption of Electronic Health Records as measured by organisations like HIMSS Analytics. One reason for the slow adoption is the cost and complexity of implementing effective technologies that truly support the needs of the stakeholders. E.g., in the 1990’s the IT requirements of a hospital with 300 beds was considered the equivalent of a bank with 180 branches (Groom DA, 1990). Technology and management have come a long way since then, yet the industry still has numerous opportunities to improve by embracing the state of the art.
What is a digital hospital?
Over the last 30 years a quiet revolution of convergence has transformed the key technologies used in the delivery of patient care. The instruments and equipment used for care delivery is now mostly digitally based, meaning that they incorporate some level of digital processing and connectivity. It is uncommon to find medical equipment such as IV pumps, vital sign monitoring tools etc., that do not have an interface able to communicate with external IT equipment. Not to mention larger scale equipment found in radiology, laboratories etc. Even modern building management and communications systems can be connected and there is an growing plethora of sensors, now commonly referred to as “Internet of Things” and advanced logistics equipment, such as connectable automated guided vehicles, subject to monitoring and control by external systems. This convergence of technologies is the foundation of a digital hospital.
The opportunity to take advantage of this technology convergence to support and make hospital workflows and patient care more effective is enormous. One only needs to look at how nurses are spending their time in hospitals, with comprehensive studies showing that less than 20% of the nurse’s time is spent on direct patient care (Hendrick A, 2008).
The vision of the “Digital Hospital” includes taking advantage of these technological advancements by integrating the different technologies and enabling them to work together to create a “real-time” information environment.
As systems of engagement (lightweight IT) they not only capture information but also act, often automatically without human intervention, on the information being collected. This enables more effective care delivery and hospital operations.
Important lessons were learned from the implementation of the St. Olav’s Hospital in Trondheim, where DNV Imatis had a vision of developing an environment for a better day to day user experience for staff and patients. Not only where the doctors and nurses were key stakeholders, but patient engagement and self-service, staff mobility, catering services, hospital porters, maintenance services and housekeeping staff, were all included. What started as a vision for a better daily experience further evolved and brought benefits not initially envisaged through a “generative effect” Bystad (2016).
Subsequent projects, building on early experience, have been developed and implemented in different directions as technology evolved. The term lightweight and heavyweight IT was pioneered by Professor Bygstad and Morten Andresen, the founder of DNV Imatis.
With the addition of modern-day advanced analytics (Big Data), artificial intelligence, cloud services and mobility, the digital hospital facilitates orchestration of process flows, identifying bottlenecks and delays, predicting future flows, empowering leadership to manage care delivery in real-time and prepare for future workloads.
Another way to think about this is through the analogy of air traffic control,
where a command centre controls the flow of air traffic, except that in a well designed and implemented digital hospital this function can be virtual. With staff being the single largest cost to hospitals, these tools help to manage staffing levels more precisely to meet demand, maintain good service, yet manage costs effectively e.g. by reducing overtime.
What is the first step?
The first step in any digital hospital project regardless of whether it’s for a new build or an upgrade to existing facilities, is to create a vision of how the organisation will leverage technology to achieve its organisational objectives, improve the patient experience, optimise safety and care quality, staff productivity and satisfaction. It is also important to set realistic expectations for what to achieve. Do all the staff have sufficient digital competence, has the management a rational plan for how to take advantage of the opportunities a digital hospital can offer, is there a plan for process improvement, change management and other important tasks?
A common fallacy is to set the goal to become digital and the world’s most modern hospital, as the focus, ignoring other important steps that can be underestimated, and are in the shadow of the enthusiasm at the implementation phase. When opening day arrives, hospital leadership discovers that the organisation is not prepared and does not have the skills to take advantage of the technology.
Usability is also of high importance, when several blocks of technology are implemented in an integrated fashion. Do staff need to log on to multiple systems, enter the same information several times, with user interfaces that are completely different from system to system. An important usability feature is for an IT system to open a new application and still maintain the context the user is working on. This is difficult and complex for staff to learn. Do clinical staff get the right information at the right time and at the right locations?
Another important usability attribute is to make the user interface role based, to avoid overload of information, protect security and confidentiality of the information. Does management have the real-time dashboards with practical and real-time KPI´s to monitor the bottlenecks and processes going on in the facility?
The implementation is not a one-off project, but a continuous improvement journey with multiple phases that will enhance organisational maturity and its ability to benefit from technology. It requires a blueprint and enterprise architecture with careful strategic planning and a high-level implementation plan.
As organisational requirements and technology evolve over the course of the journey, planning and priorities must be regularly adjusted. The vision will, however, not materially change.
DNV Imatis has taken all these learnings over the past 20 years into account when developing their concept of smart healthcare solutions.
Critical success factors
In the beginning the digital hospital was not about a single system or solution, it’s was a framework and a platform that describes how to take advantage of different technologies to achieve a higher level of productivity, better patient care and higher levels of staff satisfaction by integrating the main technology pillars of medical, building management and communications on a single IT platform. Having been involved in several greenfield projects in the Nordics, Australia, and Canada, DNV Imatis has further invested and developed the technology to new levels ensuring success. Many of the innovations available today were conceived in lessons learned during the last 10-15 years from these projects.
The role of a master systems integrator (MSI) is key to the successful and efficient technical implementation of a digital hospital. Healthcare services have specific needs and requirements that can only be learned by experience and acquisition of tacit knowledge. This MSI needs to be engaged early in the build cycle to help define requirements and select the different systems that ultimately must be integrated. The MSI will bring the knowledge, experience, and tools to ensure success at reasonable cost. We have observed through the various projects, that having this role filled early helps avoid costly mistakes and suboptimal outcomes.
Historically hospital integration focused on integrating various systems of record like LIMS, RIS, PAS and EPR using HL7 messaging and other common message types. The focus being on a single
patient in a hierarchy of data views on a desktop computer. The digital hospital brings additional non-traditional integration of:
• Logistics systems such as pneumatic tubes and automated guided vehicles.
• Building management systems like fire alarms, elevators and access control.
• Communication systems like messaging and video communications.
• Sensor technologies like real-time location services.
• Integration technologies like enterprise message service or service bus.
To maintain the battery life of mobile devices and to turn data into realtime value for the role-based user, it is important to both support push/ messaging of alerts and alarms as well as a more service-oriented integrations based on Rest and FHIR. There is now a trend to move to service-oriented integrations, in our experience both methods are important to combine in the real-time digital hospital environment.
The focus is on the whole system in real-time, creating an opportunity to manage and act on what is happening now. By monitoring the processes in real-time, bottlenecks and changes occurring through the working day can be resolved and responded to, not just once but throughout each shift. At the beginning of each shift, bottlenecks often emerge because someone called in sick and there is a resources shortage in some departments. At lunch time, a bottle neck can emerge because the beds are not cleaned in time due to doctors completing their rounds too late. Later, focus can be lost due to a
triage bottleneck in the emergency department.
By integrating all these work processes with a realisation that every department is interconnected and applying AI and real-time status, priorities can be automated and resource focus adjusted as remediation to optimise flow.
In a 2018 Institute of Healthcare Improvement White Paper (Rutherford 2018) the authors highlighted: “Optimising hospital flow, and ultimately improving outcomes and the experience of care for patients, requires an appreciation of the hospital as an interconnected, interdependent system of care” (Patricia A. Rutherford, 2018).
Even if there are rostering systems and resource management systems in place to plan for the doctor schedules, nurses shift plans, and the capacity of the housekeepers, these systems only plan the capacity for the next weeks and months, they lack functionality to remediate situational changes that can happen in real-time minute by minute.
Only a real-time integrated system can give the hospital managers the tools and control to manage and orchestrate the activities of thousands of staff members, including doctors, nurses, hospital orderlies, technicians, housekeeping, catering, security, patients etc in an effective and efficient way. Only the right mindset, business knowledge and a realtime integrated system that automatically dispatches data to the appropriate actor forms the digital hospital of the future –today.
We call this micro-management, without focusing on the details, the digital hospital sets the overall goals, the integrations and technology do the smart automation capable to orchestrate and even choreograph minute activities.
DNV Imatis encapsulates over 20 years of experience and learning, from delivery of 7 digital hospitals and absorbed significant investments and development innovation to achieve this vision, not in the future, but now.
Benefits of a digital hospital
After having implemented a significant number of digital hospitals, we have observed numerous benefits to different stakeholders that can be described as follows:
Management
A digital hospital is about continuous improvement. It will enable management to make better decisions, increase staff satisfaction and retention as it enables care providers to focus on delivering patient care, rather than administrative tasks or wasting valuable time looking for information, equipment or supplies.
The digital hospital is also an important tool for business improvements, monitoring of real-time bottlenecks to improve patient flow, real-time bed status, patient satisfaction and much more. There needs to be a management culture to leverage the opportunities offered by the digital hospital. Easily said, and very often underestimated when implemented. Change management is difficult in any organisation, small and large.
Constructing and operationalising a new hospital represents one of the greatest opportunities available to transform the organisation and work in new smarter ways supported by technology. This includes changing workflows, discovering new options for change, as well as organise for optimal patient safety and treatment, yet while simultaneously reducing the cost of staff.
In some cases, we have observed that management commits to divert operational budget allocations to capital expenditures to invest in the tools offered by a digital hospital anticipating that the investment will yield productivity returns lowering operating expenditures in perpetuity.
Patients
The patient will benefit from better care delivered by more satisfied staff, higher patient safety due to decreased probability of error, a more engaging environment in terms of participation, better communications with caregivers and family, and overall level of satisfaction.
The main activity of a patient is to wait. There are fewer patients waiting in a digital hospital. We also observe that as an effect of the Covid-19 pandemic, virtual care and remote treatment has changed from curiosity to necessity. In examples where patients’ check in, provide payment and self-registration of information on their own private smart phones or kiosks and use video chat, reduces the interaction and direct contact with staff, lowers the risk of infection transmission.
Caregivers
With higher levels of automation, caregivers can allocate more of their time to core activities that matter such as direct patient care.
The ability of the digital hospital solutions to orchestrate and choreograph activities removes uncertainty about what to focus on next, yielding better flow. Key actors for improving patient flows are doctors, nurses, support services and management. Better collaboration between caregivers and clear traceable communication ensures more secure handoff of responsibilities and makes them better informed about the patients.
The system ensures that everyone is aware of their roles and responsibilities. Ultimately, we have seen this translate to improved productivity, better quality of care and higher levels of satisfaction (Ausen, 2017).
Use of mobility is ubiquitous and successful worldwide, but in healthcare many still trust the old technology platform of a pager to be the most important communication device in hospitals. Delivering modern hospital care requires teamwork of dozens of clinical actors. They must be synchronised in their activities and be aware of the activities of each other. They are a mobile workforce.
Today, a modern smart phone can completely remove the pager, with advanced communications infrastructure designed and configured to enable secure devices that never lose data, and if data is not received at the end point, secure and smart routing is applied. The DNV Imatis mobile solution is designed
and built to take care of abnormal situations.
Innovation
One of the many advantages new build hospital construction affords is the opportunity to innovate and push the boundary of the possible. Technology advancements have introduced a new “knowledge regime” we collectively call “lightweight IT”, rooted in the consumerisation of IT, and does not require professional IT intervention to support applicable use cases vs more traditional “heavyweight IT” that does. It encapsulates mobility and the simple mobile app paradigm.
Bygstad (2017) defines “Lightweight IT” as: “Lightweight IT is suggested as a term for the new knowledge regime of mobile apps, sensors and bring-your-own-device, also called consumerisation and Internet-ofThings”.
Lightweight IT empowers users to customise and configure the technology to their needs. We’ve observed how users improved care delivery and operations once they’ve learned how to use the tools and tailor them to their work patterns, as described by (Halvorsen, et al., 2019).
Stories and references of success
DNV Imatis has developed a method of how to implement a successful digital hospital, with a unified solution for optimising the workflow using mobility, information sharing and collaboration in real-time, across the clinical staff as well as for all the service functions that are important for a lean patient flow, as well as optimal use of and resources allocation for doctors, nurses, beds, and expensive medical devices.
Here are few examples of successful digital hospital projects:
New Royal Adelaide Hospital, Adelaide, South Australia
A major public/private partnership enterprise, the New Royal Adelaide Hospital is leveraging many of the lessons learned from the early Norwegian adopters and has implemented a comprehensive state of the art technology framework to make the hospital one of the best in the world.
The project involved several blocks of technology, DNV Imatis and HP delivered the integration and messaging engine for mobility to the hospital.
The block of technology for selfservice and queue management was delivered by DNV Imatis in a contract directly to the Regional IT service, inside SA Health.
Hospital in Østfold – Kalnes (HIMSS level6)
A good real-life example is the new hospital in Østfold Kalnes (HIMSS level 6) and Haraldsplass Hospital in Bergen, Norway.
The Østfold Hospital decided to manage the digital hospital implementation with their own project organisation. There were several contracts awarded procuring big blocks delivered by several companies.
DNV Imatis won the projects for the enterprise integration and messaging engine (70 different integrations), replacing pagers using 1800 Apple smartphones, silent nurse call solutions, nurse’s mobile app for collecting vital sign and check lists for patient safety, solutions for hospital orderlies, housekeeping, and meal management.
DNV Imatis also delivered the analytics platform based on the Microsoft PowerBI technology. The experience and learning of implementing the Østfold and Haraldsplass hospitals, the two most recent operational digital hospitals, brought the DNV Imatis software suite into a unified solution enabling a holistic approach to the implementation of a digital hospital. A detailed study of the Østfold project in Bygstad (Bendik Bygstad, 2020).
Haraldsplass Diaconal Hospital
Is one of the World’s most modern and successful Hospitals delivered by DNV Imatis.
Haraldsplass is one of the hospitals in the western region of Norway. The hospital opened 4 years ago and has diligently documented the benefit of using the technology blocks. The success of this digital hospital has now led to a full roll out of the DNV Imatis technology to all hospitals in the region, including the Stavanger University Hospital that is currently under constructing. The success of the Haraldsplass hospital is attracting visitors from all over the world to observe what a unified approach to the digital hospital can deliver.
Haraldsplass annual report (NO)
The link to the hospital annual report,there are several examples of the uses of the DNV Imatis solution implemented and its outcome. The management team has established a fantastic team of resources that is innovating further the digital hospital in close cooperation with the regional health service organisation Helse Vest-IKT and DNV Imatis. The successful innovations will be a part of the ecosystem and will be rolled out to the other Hospital in the region once thoroughly tested.
Kainuu Hospital in Finland
Opened in 2020, and was a project delivered as a co-operation between Tieto Evry and DNV Imatis.
The focus was the integration engine, patient journey board and self-service solutions for patient. The DNV Imatis solution was integrated into the Microsoft Office for resource management of examination rooms, the solution was also tightly integrated with the new version of the modern patient record from Tieto Evry named Lifecare, as well as several other integrations.
The hospital introduced the DNV Imatis integration and messaging engine in the project.
Stavanger University Hospital (SUS) 2025
- On-oing project
One of the new greenfield hospitals that is under construction. The hospital will implement the DNV Imatis solutions as key element in the digitalisation of the new hospital.
Norlandssykehuset
Was a greenfield project in north of Norway, that decided to implement the digital hospital blocks.
DNV Imatis delivered smart rostering, triage, real-time scheduling, selfservice check-in technology, digital signage, bed management, patient flow tools, mobility, and integration and messaging engine in the project. The Nordlandssykehuset also was one of the key innovators using DNV Imatis to manage the infection tracing and workflow regarding the COVID-19 pandemic.
The hospital will open in 2025 and is one of two university hospitals on the west cost of Norway. DNV Imatis will deliver an integration and messaging engine, mobile portal to enable the use of a unified communication for all staff, digital whiteboards for patient journey and clinical logistics, triage and patient safety. Signage, self-service kiosk and mobile patient registration, solutions for support services as orderly, meal management, housekeeping, and technical services will also be on the DNV Imatis platform.
All data from the system, including the building IT will be collected in the report and analytics database, that feed the data into the regional date warehouse managed by the internal analytical staff. The database is integrated to the regional datawarehouse delivered by the internal IT resources. The DNV Imatis application is installed at the regional redundant data center, and will be used by all the hospitals.
Hospitals overview (NO)
Nordmøre and Romsdal SNR - On-going project
Greenfield project operational by the end of 2025. They want to reuse as much of the technology developed and move into the new hospital.
DNV Imatis is responsible for the mobility, integration- and messaging engine including more than 20 interfaces to other ICT systems. The system will also be integrated into the regional health platform based on Epic EMR.
These are a few examples of world leading originations that have adopted the principles of a digital hospital and are taking advantage of healthcare technology convergence by integrating different technology domains.
To build a digital hospital requires active involvement of administrative, clinical and technology leadership. Technology governance is critical as all the different technology blocks must be managed by single technology leadership, accountable for all the technologies within the healthcare organisation.
Traditionally healthcare organisations have different organisational functions managing different technologies in silos, e.g. biomedical engineering managing medical devices, facilities managing building technologies, IT department managing information technology etc. It’s hard to achieve synergies and compatibilities across the silos.
A digital hospital is not a technology project, although enabled by technology but rather an organisational improvement program.
As significant costs for healthcare organisations are their human resource costs, the focus needs to be about making hospital staff better equipped to spend time on the most important activities and less on waste. There is ample evidence to suggest that substantial opportunities exist in most health organisations to improve resource allocation, information management and care workflows.
References:
Ausen, A. e. (2017). UTVIKLING OG IMPLEMENTERING AV DIGITAL SAMHANDLING OG OPPGAVESTØTTE PÅ KAD. Oslo: SINTEF.
Bendik Bygstad, E. Ø. (2020). Architectural alignment of process innovation and digital infrastructure in a hightech hospital. European Journal of Information Systems, 220-237.
Drucker, P. F. (2002). Managing in the Next Society. New York, NY: St. Martin’s Griffin.
Groom DA, H. J. (1990). Evaluation and selection of systems for automating clinical operations. Biomedica Instrumentation & Technology, 173:185.
Halvorsen, M. R., Austad, H. O., Landmark, A. D., Ausen, D., Svagaard, I., Tomasevic, T., & Trondsen, T. (2019). Redesigning Work With a Lightweight Approach to Coordination Technology. Computers, Informatics, Nursing, 124-132.
Hendrick A, C. M. (2008). A 36-Hospital Time and Motion Study: How Do Medical-Surgical Nurses Spend Their Time? The Permanente Journal, 12(3):25.
Patricia A. Rutherford, R. M. (2018). Achieving Hospitalwide Patient Flow, The Right Care, in the Right Place, at the Right Time. Cambridge: Institute for Healthcare Improvement.
Stabell, C. F. (1998). Configuring value for competitive advantage: On chains, shops and networks. Strategic Management Journal, 413:437.
Authors:
Baldur Johnsen, VP International Business is an information technology executive with over 30 years of wide-ranging experience in IT related business and health IT. He was a Hospital CIO in the Nordics for 10 years and the worldwide healthcare provider director for Hewlett-Packard’s Enterprise Business; in that capacity he led the HP Digital Hospital Program. He has been a non-executive board member of DNV Imatis. He holds university degrees in Computer Science and Business Administration.
Morten Andresen is the founder of DNV Imatis AS. He has been involved in digital hospital projects for more than 20 years. He´s been in different roles, starting as a software developer, a system architect and later as a key resource in several of the digital projects. He was also one of the key architects and innovators of the smart healthcare solutions used in several digital hospitals, as the pioneer of the concept of lightweight ICT in co-operation with Professor Bendik Bygstad. He holds advanced technical degrees from the University of Trondheim.
