The Liquid Hospital

richard-colbridge-bw (1)The Irish healthcare system has been on an exciting journey putting building blocks in place to create a digital fabric. In December 2014, it was said to be 16 years behind the digital curve for health in Europe. Over the past two years Ireland has been able to ‘catch up’ 6 of those years, and by the end of 2016 four more of those years had been chipped away as the progress gap closed.

There are a number of key projects that have become the foundations of all change and reform to the Irish healthcare system, these include; an Individual Health Identifier, eReferral, ePharmacy and Ireland’s first digital hospital.

The Irish healthcare system can now uniquely and digitally identify every patient and member of staff increasing the ability to deliver enhanced patient safety significantly and the ability to manage performance based on information ten-fold. The system has broken down physical boundaries relating to the referral process by implementing fully an eReferral process completely in less than 12 months. The ability to prescribe in the community using a process that maintains patient choice of pharmacy has been piloted successfully and is now implementing nationally.

The first fully digital hospital has been delivered into one of the busiest maternity hospitals in the EU and will now be implemented into every maternity system in Ireland. This solution sees IoT technology brought into the most complex of care delivery systems, saving lives through real time information analysis and the implementation of digital workflows across a whole care pathway - a first in the world.

This has led to many conversations around the breadth of how eHealth can change care delivery globally. Recently I was discussing how this can affect delivery of care, particularly in hospitals, with a learned colleague of mine who has come up with the phrase, the ‘Liquid Hospital.’ Which I must say has grabbed my imagination completely.

The concept of a Liquid Hospital is not just supported by technology but is only possible through technology and modern innovation. It’s no stretch of the imagination to picture it, yet the ‘liquid hospital’ will require a large amount of business managed change and can’t be made so ‘just’ through the implementation of technology. The thinking is starting to mature here and in November Ireland’s minister for health began to use the phrase, “a health system without boundaries.” After all digital doesn’t recognise the ‘physical’ boundaries of a hospital or GP clinic.

Moving away from concepts of episode-centric care will be a significant challenge any health care system worldwide. Let’s not forget even the concept of an Electronic Health Record (EHR) is based around recording the episodes of care that occur rather than around the patient. Breaking down the systemised walls for the provision of care will be key to the innovation that we describe here as the Liquid Hospital.

Yet even as the concept evolves, we note a flaw in the name. The Liquid Hospital does not refer to one institution or hospital - the concept really is around the delivery of seamless care and wellbeing support to people (not just patients), however for the purposes of this article let’s stick with the name as a term.

Simple Concepts

The idea is quite simple really; once the patient is in hospital the technology allows the episodes of care that the patient requires to come to them, rather than the patient being shipped around the hospital for different treatments and the risks that come with that. In other words, the system becomes clinical centric. I know from a stay in hospital in 2016 that being moved from ward to treatment room and back again is at best uncomfortable and at worst downright scary. The concept doesn’t just stop there though. It seeks also to achieve that panacea of eHealth - a truly paperless environment. So that not only do treatments flow around the patient, so does information.

Imagine an outpatient visit to a liquid hospital. You arrive in reception and check in with a clinician who takes your identification and confirms back to you some details allowing you to confirm the reason for your visit. As a patient you have elected to collect information on your condition at home so you quickly synchronise the smart device you have with the hospital systems. This shares your medication record and real time recordings of how your condition makes you feel.

As your consultant comes to you they are fed this information to their tablet or computer and are analysing the outputs in the lift as they come to meet you in your own personalised consultation room. As the consultant comes into your room your records are shared on the display on the wall for both you and the consultant to consider. You have also elected to share the consultation output with your primary care professional and therefore the actions the two of you now collectively take are recorded and made available to them digitally and directly into their system ready for next time you the patient are with them.

Let’s say you elect to have a procedure related to your long-term condition. Whilst with your consultant you choose when and where that procedure will take place and you are electronically introduced to the clinician who will be your key point of contact when you return for the procedure.

Your consultant is then able to provide advice on what you need to do before coming in to hospital for the procedure and download this advice to your smart device for you to consider with your family when you are home.

Perhaps you also consider a slight change to your medication. The consultant is able to provide you with advice and guidance from around the world and connect you to patients like you with a similar condition via a secure social media outlet. This allows you to consider the impact of a change in medication with a peer group over the coming weeks and access some key support.

Your clinician can provide your new prescription directly to the pharmacist of your choice and you can call there on the way home, knowing your drugs will be ready for you. A copy of your prescription and your summary notes are also made available to you for your own health record as you have elected to keep this information in your own health vault solution in addition to the electronic record in the hospital.

A few days later, your long-term condition takes a turn for the worse and you decide to drop into the primary care centre, which is in your village. You ring the centre and are asked to provide the information you have collected over the last few days via your smart device, which you can do whilst you are on the phone. The primary care centre advises you to up the dose of medication ever so slightly and alter the time you are taking your prescription and within one day your illness settles down and you don’t need to go in to the centre.

The time of your procedure and your short stay in hospital draws ever nearer. Rather than have to attend the hospital for a pre-op meeting you have decided to share your own collected data with your key contact in the week leading up to your visit and have a brief video conference with the clinician. All is looking well and the clinician does not need to see you face to face. Although you are a little anxious, the hospital has arranged for you to be part of a secure group on a social media site and you are able to communicate with patients from around the world who have been through a similar experience, and this goes a long way in settling your fears.

On the day of your attendance at hospital you check in comfortably with very little fuss. You are provided with a secure tablet PC that is linked to the hospital’s Wi-Fi, and all your notes and updates will be on this device during your stay so that you have the comfort of seeing them as well as them always being with you during your stay. It’s your choice throughout your stay as to who you additionally share the information with, electronically. You elect to send all information to your own personal record and some of the key facts to your primary care centre. You also decide to email your nearest and dearest a summary of each day to help them feel less worried about your time in the hospital’s care.

After the procedure you are out of hospital very quickly. Your after care is already arranged and as you hand back the hospital tablet computer with your information on you can already see it has arrived both in your own personal record and at the primary care centre.

The social care provision you require in the first few days is arranged online and again, as the patient, you have decided what information to share and with who. The social care clinician visiting you at home asks if they can view your record in more detail and you grant them access there and then. The information they are able to get from this satisfies any initial concerns they had and they are able to discharge you within three visits.

A Stretch of the Imagination?

The technology is there to facilitate this. It has been available the last five years at least if not longer. The big change needed is perhaps twofold; investment in the aspects of technology to drive this (including training and development) and the change in how care is delivered at a business and service level. Healthcare provision and change related to it is often compared to changing the direction of a sea bound oil tanker, but, if the description of this kind of benefit can be brought to a wider audience, and receive buy in from clinician and patient alike maybe this could be an innovation we can make reality! It certainly describes a system that puts the patient at the centre and yet is only just beyond our own reach. A tangible view, just over the horizon of eHealth in action.

Some countries across Europe are starting to put in place the building blocks to enable this change: in Scotland, a change to the commissioning model, facilitating health boards across all care delivery to allow the holistic delivery of care and here in Ireland, the HSE’s own integrated care programme and reform programmes beginning the concepts of change, the creation of the Individual Health Identifier spoke about above and concepts like ‘money follows the patient’ will all start to enable this dream to become reality.

Technology and a business change programme truly can break down the physical walls of the care institutions of the country and allow care to flow around the patient in a manner as transparent as H2O.  Our 2020 vision sees health without walls made possible by digital advancements.