Ballinger Senior Principal Louis A. Meilink, Jr., FAIA, FACHA, ACHE contributed to the cover story of Health Facilities Management’s October issue. The article, “Planning Facilities for Telehealth,” describes considerations for designing healthcare environments that accommodate rapidly evolving technology.
Excerpted from Health Facilities Management, a monthly publication of the American Hospital Association:
Remote provision of health care services — often referred to as telehealth or telemedicine — has grown in importance, especially with COVID-19-related restrictions on in-person interactions.
“We know consumers want telemedicine,” says Louis A. Meilink Jr., FAIA, FACHA, ACHE, senior principal at Ballinger, a health care design firm in Philadelphia. “And from a space perspective, telemedicine can be anywhere, from primary and ambulatory care centers, cancer centers, emergency departments, patient rooms, and many other clinical and nonclinical spaces. Implementing telemedicine is a matter of having technology in the space where it’s needed and providing the supporting clinical care model, access and reimbursement structure.”
As Meilink notes, the range of telemedicine applications is broad. Remote clinical care encounters can include a physician with a patient in a hospital; a caregiver with a patient at home; a specialist with a patient and caregiver; caregivers meeting with each other; and remote monitoring of patients in a hospital or home care setting.
Consequently, the creation of effective telehealth spaces is today more important than ever, and telehealth should be considered early in the design phase of a new or renovated health care facility. That hasn’t always been the case, experts say.
“Telehealth is one of those things that has often been an afterthought,” says Bryan Arkwright, co-founder and chief research officer of Cromford Health, a digital health research and advisory firm. “But the facility issues are important. Those details can stop or slow a project.”
As a sign of this growing recognition, the Facility Guidelines Institute (FGI) Health Guidelines Revision Committee (HGRC) established minimum requirements for telemedicine spaces and offered additional recommendations supported by research and best practices in its 2018 Guidelines for Design and Construction documents for hospitals and outpatient facilities.
Additionally, the brief telemedicine guidance provided in FGI’s 2018 Residential Guidelines has been expanded significantly for the 2022 edition.
Dedicated, integrated or mobile?
According to the American Academy of Family Physicians (AAFP) website, telehealth is different from telemedicine in that it refers to a broader scope of remote health care services than telemedicine. While telemedicine refers specifically to remote clinical services, telehealth can refer to remote nonclinical services and electronic information sharing, AAFP states. In practice, however, the terms often are used interchangeably.
Perhaps the first design decision that has to be made is whether the system will include dedicated spaces for telehealth; mobile carts that can be rolled from space to space; or telemedicine tools integrated into patient rooms, exam spaces, conference rooms or doctors’ offices.
“Telehealth can be deployed in any room anywhere in a facility,” says Rebecca Lewis, FAIA, FACHA, CID, director of health care design for DSGW Architects in Duluth, Minn. “You can talk to someone on an iPad, a screen within an exam room or in an office space. You just need to know what’s the best spot to deliver the right kind of care.”
The decision about which form the telehealth facilities will take comes down to a number of variables, ranging from finances to the deployment strategy, with planning strategies including:
Teleheath carts. A hospital or outpatient facility with limited money available to invest in telehealth may choose to make it available on carts that can be wheeled from room to room as needed. Outfitting a cart may cost more than integrating telehealth equipment into a patient room, but using carts can save money because a relatively small number of carts can serve multiple patient rooms and other spaces. Carts can be cumbersome, and care needs to be taken with their cords, but cart-based telehealth is a viable solution for many facilities.
Integrated setups. Many hospitals have opted to build telehealth tools directly into patient rooms. Similarly, ambulatory health facilities that include telehealth sometimes integrate the tools into exam rooms or conference rooms. An integrated setup can be the most convenient, and the equipment — such as the TV monitor — can be used for other purposes when not needed for telehealth.
Kaiser Permanente has integrated telehealth equipment into some of its patient rooms and uses telehealth carts to serve others.
“Our newest hospital, Kaiser Permanente San Diego Medical Center, is equipped with monitors and two-way videos in each of our patient rooms,” says Angelene Baldi, AIA, EDAC, executive director of facilities strategy, planning and design for Kaiser Permanente and a member of the HGRC. “This can be used for telehealth appointments and is also used for entertainment, educational programs, food orders and more. In our older facilities, we use mobile video carts that can be wheeled into patient rooms for video appointments. These serve a dual purpose and can also be used as charting stations for nurses and clinicians.”
Kaiser Permanente’s telehealth program — which is currently handling 55% of the system’s ambulatory care visits — puts a premium on flexibility, says Zack Ryan, executive director of information technology capital project delivery. He says the facilities are designed to allow physician and patient interactions in a wide variety of situations.
“These tools need to be available to both our members and our providers in as many different situations and modalities as possible in order to deliver the optimal digital experience that can truly augment our in-person interactions,” Ryan says. “Our telehealth platform is built so that a provider can take their appointments and ad-hoc visits from their office, clinical spaces, home or other remote locations on a variety of devices. We also created this flexibility for our members and patients.”
Dedicated spaces. Dedicated telehealth spaces take several forms. Some are designed exclusively for caregivers treating patients remotely, while others are set up so patients and caregivers can be in the dedicated room together and access another caregiver — a specialist, for example — via the telehealth equipment. The advantage of a dedicated space is that everything in the space can be optimized for telehealth.
At least one facility, Mercy Virtual Care Center in Chesterfield, Mo., is entirely composed of dedicated spaces. According to Mercy’s website, caregivers at four-story, 125,000-square-foot Mercy Virtual facility provide around-the-clock supplemental assistance and monitoring to caregivers in the 43 hospitals that make up the Mercy system and other facilities outside Mercy.
However, in some cases, dedicated spaces are not used enough to be worthwhile, says Patricia Shpilberg, M.Arch, vice president of planning and development for MedCraft, a health care real estate development firm headquartered in Minneapolis. She adds that access and ease of use are as essential for providers as they are for patient adoption of the technology.
“We had a client who had dedicated telehealth spaces away from their clinics and offices for providers to use during their virtual care sessions,” Shpilberg says. “The result was a limited adoption rate due to the disruption to their workday. Once the hospital integrated telehealth systems into the office work environment, the provider adoption rate started to rise.”
“There are a lot of times the patient is not present in an initial complex case discussion between providers in different specialties, so that’s why that larger telehealth suite was developed: to allow for ease of use and connection with multiple caregivers,” says Jennifer Ruschman, senior director of the center for telehealth at Cincinnati Children’s Hospital.
Cincinnati Children’s Hospital has a mix of telehealth systems, but their mix includes several dedicated spaces, including a telehealth conference room that seats 18 to 20 people.
Sometimes a facility simply can’t afford to set aside space solely for telehealth, says Lewis, who regularly works with small rural facilities where budget is limited. In those facilities, a conference room or exam room might be optimized for telehealth but made available for other uses when it’s not being used for telehealth.
Regardless of whether a facility opts for dedicated, integrated or cart-based telehealth, experts say flexibility is essential.
“You need to build in flexibility because technology changes constantly,” Meilink says. “Especially on larger projects, the technologies you’re designing for in year one or two may not be what you’re going to install in year five when the building opens. You need to consider infrastructure — such as wireless technology and systems pathways — that enables future changes, including accommodating technology that doesn’t yet exist.”
Ryan says that is exactly how Kaiser Permanente thinks about its telehealth installations.
“It’s challenging to build for the future, with rapid development and changes in technology,” Ryan says. “The building timeline for hospitals is around five years, from design to opening, and telehealth solutions, use cases and infrastructure are very fast moving. The key to success is to plan and design hospitals for what you want the future patient experience to look like, and to create room for flexibility in the design and technology capabilities.
“Kaiser Permanente strives to enable all of our new facilities to support telehealth, rather than only building these requirements into specific projects,” Ryan says.
Many design elements of a telehealth program are similar regardless of whether the equipment is on a cart, integrated into a patient room or doctor’s office, or set up in a dedicated telehealth space. Every telehealth endpoint — that is, where the system connects to a caregiver or a patient — should meet some basic best practices to ensure an ideal experience for all involved parties.
Arkwright says that the standards used by the film industry — such as good lighting, proper acoustics and effective camera angles — should apply to telemedicine as well.
“Imagine the professionalism CNN or ESPN takes in its productions,” Arkwright says. “Sometimes just the opposite goes on in telehealth. You can beam into a health system and the lighting is terrible, the background is dark, the doctor’s face is washed out and they’re hard to hear. Compare that to when everything is optimal or professional grade. That’s probably the difference between a patient perceiving, ‘This is high-quality care or not.’ These little things are important.”
The following guidelines apply regardless of the endpoint — a patient or exam room, a physician’s office, a conference room or a dedicated telehealth space:
Room size. With the right technology, telehealth can be deployed in any size room. Thus, a facility that is renovating an existing space to accommodate telehealth can create a program regardless of how small the room is. However, in a newly designed space or a renovated space that can be expanded, a larger size is desirable. The FGI Guidelines suggest that “the room should be large enough for the patient and the patient presenter, if one is present, to move about comfortably. The patient should be able to sit in a chair as well as use the examination table … Where the examination includes gait evaluation, the room should provide sufficient space for this activity to be captured by the screen.”
Surface colors. The space should be painted in a nonglossy, neutral color. Light blue or light gray work particularly well, Arkwright says. “White can be a little sterile or too bright, and yellow doesn’t do well on camera,” he says. “If the patient room is painted yellow, the patient might look like they have jaundice.”
Ruschman says they considered paint color carefully when designing the dedicated telehealth spaces at Cincinnati Children’s Hospital and came up with a combination of colors that looks good on video and blends well with the hospital’s brand color palette.
Lighting sources. Ideally, the light source should be bright and positioned in front of the subject — the patient or the caregiver — so that it illuminates the face clearly. Natural light is good for accurately rendering color, but it’s difficult to control, so if the space has windows, make sure they can be covered when the natural light is not flattering.
At the Liberty Campus of Cincinnati Children’s Hospital, which features telehealth equipment in each of its 40 patient rooms, natural light is controlled by blinds. “We don’t want to limit the natural light in patient rooms, but it can cause shadows, so we address that as part of our training,” Ruschman says. “We teach users how to do a self-view check — if it’s not good, they pull the blinds.”
Regardless of the light source, it should be balanced and distributed, says Ellen Taylor, Ph.D., AIA, EDAC, vice president for research at The Center for Health Design in Concord, Calif. “You need frontal lighting so there are no shadows,” says Taylor, who is a member of the HGRC. “But you also don’t want someone to look washed out, so depending on the task and type of treatment, the color and brightness of the light matter, too.”
A technical measure of how well a light bulb renders color is the color rendering index (CRI), which ranges from 0 to 100. Natural sunlight is 100, and a dim streetlight is about 0. Sometimes CRI is not indicated on a lightbulb package, but if the bulb has a CRI of 90 or more (which is preferable), it usually will say so on the package. The FGI Guidelines call for lights in telehealth spaces to be warm, white light — 3,200 to 4,000 Kelvin.
Endpoint background. Designers should consider the background of a TV newscast — if it’s not an image related to the newscast or the network logo, there’s usually not much there. That’s because the network wants the viewers to pay attention to the anchor, not the background. Designers should have the same goal for the background of the caregiver endpoint; it should be neutral enough that the patient pays attention to the doctor, not a cluttered bookshelf in the background.
“You want to make sure that whatever the patients are seeing behind the provider is a good image for your system,” Shpilberg says. “Sometimes that space is used for branding or education.”
Acoustic issues. There are two issues to consider in telehealth regarding acoustics: privacy and clarity. Privacy can be addressed by making sure the door to the space, whether it’s a patient endpoint or caregiver endpoint, can be securely closed and that it blocks sound.
“It’s about making the patient feel like they can share information privately,” says Lewis, who also is a member of the HGRC. “Doors can be the weak point with acoustics, so perhaps you shouldn’t locate the door on a busy corridor — perhaps around a corner is better. Simple things like that can add to the feeling of privacy and make the patient more comfortable.”
Acoustic clarity results from a combination of the design and construction of the room and the technology used by the telehealth system. The designers of the dedicated telehealth spaces at Cincinnati Children’s Hospital included acoustic paneling on the walls to optimize the acoustics, Ruschman says.
Getting technology right
The heart of a telehealth system is the technology that connects the two or more remote participants. Getting that technology right can make the difference between success and failure.
Every telehealth system incorporates a monitor — or multiple monitors — of some type, and monitor technology is constantly advancing. However, putting the monitor in the right place and at the right angle is essential regardless of how advanced the monitor is. The screen should be installed so the patient can comfortably look straight on to the care provider, as if they were in the room. “You want the monitor at eye level, as if the provider were sitting right in front of you,” Shpilberg says. “You want to make it feel as real as possible.”
The position of the camera that is capturing the image — on both sides of the interaction — is equally essential, whether the camera is separate from the monitor or integrated.
“There was a fascinating study done in 2007 by Tam and colleagues that looked at gaze angle, and at 7 degrees there was a perception that the person was happier, warmer, more approachable, more interested,” Taylor says. “At 15 degrees, it’s starting to look down, and the perception was somebody was sad, depressed, or timid or hiding something. So, imagine a behavioral health visit where just the angle of the camera gives you a different perception of what’s happening with that person.”
Another technological aspect of the camera that is important is whether the caregiver can control the camera at the patient endpoint, which allows them to zoom in on a particular part of the patient.
“The remote camera control is one of the bigger challenges,” Ruschman says. “The far-end camera controls are really important to our clinicians, because they want to pan and tilt and zoom in and out. This lets them see the nonverbal cues.”
As with the camera, getting the microphone and speaker set up correctly is essential. The microphone built into monitors may be good enough for normal Zoom meetings, but Arkwright recommends a separate external microphone for better quality audio. Similarly, he recommends separate speakers — or even noise-canceling headphones — to maximize sound quality.
At the Liberty Campus of Cincinnati Children’s Hospital, separate speakers and microphones are mounted above the patient beds for maximum audio clarity, Ruschman says. But they’re working on a new health care facility, and they may integrate the audio equipment into the monitor because that technology has improved, she adds.
All telehealth systems rely on a strong internet connection. In some cases, Wi-Fi is good enough, users say, but a wired connection is always more reliable.
“We prefer to use hardwired where we can,” Ruschman says. “But most of our telehealth carts run on Wi-Fi. So, we train folks on how to get a hardwired connection, but we’ve found that usually the carts run pretty well on Wi-Fi.”
Ready for change
The facilities issues surrounding telehealth are complex. The key, those involved say, is building spaces that can accommodate today’s technology while being prepared for it to change.