2020 is, among many other things, the year the world became obsessed with data.

Since the start of the COVID-19 pandemic, we have become collectively fixated on tools that used to be the preserve of epidemiologists, public health officials and statisticians: the mounting tolls of confirmed cases and of deaths, the sharply rising graph lines and the flattening curves, the mysterious “R” rate that will determine whether or not Christmas is cancelled.

Data has also become one of our most powerful weapons against the virus: some form of contact tracing has been implemented in every country that has managed to bring infection under control, whether manual or digital. In the months and years to come, the analysis of ever larger datasets – so-called “Big Data” – will come to further define our responses, and determine our resilience to future crises.

So far, we have barely scratched the surface, says Michael Pietrzkiewicz, electronics engineering technologist at WSP in Alberta, Canada. “The more data you can gather over time, the more accurate it will be,” he says. “If we want to have resilience on-the-fly, we need to be comfortable that the data is correct or we’re not going to react to it. Big data has actually played very little part in our response to COVID, partly because this isn’t an area where enough has been accumulated. What this has actually reflected is how far we are from having a connected world.”

To look at it another way, COVID has given us a glimpse of the enormous potential of data to help us rise to future challenges. One of the most valuable, and rapidly expanding, datasets will come from the “smart” devices, equipped with sensors and network connections, that are being rolled out across buildings and cities. By collecting and aggregating information about the environment and the way we interact with it, these technologies offer a new level of insight that could dramatically improve our ability to foresee and react to events.

Few sectors stand to benefit more than healthcare, a data-rich sector on the cusp of a digital transformation.

Vast amounts of information flows through a hospital, but only a tiny fraction of it is has ever been analysed or acted upon – until now. Health informatics – the clinical application of data and digital technology – is one of the global healthcare sector’s fastest growing fields. “There has been a massive push on informatics in the last 12 months, in every part of the hospital, and informaticians are going to drive a complete change,” says John Wall, principal technical advisor at Metro North Hospital and Health Service in Brisbane, previously principal technical consultant to Queensland Health in Australia. “Smart projects fail because they don’t get to the heart of the way that humans do things. That’s the role of the informatician, to be the bridge between IT and the clinicians – they know enough to talk to the IT people, and they understand how to collect, manage and validate research data, and how it can be applied to help make better decisions.”

 Wall is currently leading the IT design for the redevelopment of Caboolture Hospital. As a regional facility, the tech is less ambitious than the A$2bn tertiary teaching hospital he completed a couple of years ago, where a fleet of pharmacy robots roam the corridors. But on this project, he’s finding that the staff are much more willing to embrace the possibilities. “With COVID, everyone’s had to learn to adapt and be agile. Normally in healthcare, the staff are too busy, but there’s been a real change in the dynamic over the last six months. There has been so much more ownership and interaction, and people are more open to working through the solutions and being a part of them.”

At the heart of all smart hospital solutions is a robust digital infrastructure. In physical terms, this means installing wires – to support a dense wireless network – and sensors, which can collect data about the environment and track the location of electronic devices such as smartphones and RFID tags. Once that basic network is in place, it can be used for many things, from alerts for malfunctioning systems, to mapping people, equipment and supplies, to the digitalization of hospital processes and flows.

This can support resilience – the ability of a hospital to operate safely during a crisis – in many ways. Reliable location data could help maintain two different streams for infected and non-infected patients and associated equipment, for example, and manage stretched resources more efficiently. Advance warning of building system failure – from machine-learning analysis of sensor data – would enable maintenance teams to avoid outages. Supplementing the human workforce with robots, to clean or deliver supplies, reduces the risk of disease transmission and minimizes exposure for caregivers and patients.

“Autonomous guided vehicles can be used to transport food and medicine, so hospital staff don’t need to go into the ward,” says Thomas Chan, Executive Director of Building MEP at WSP for the China Region. He is part of the team designing a smart hospital in Hong Kong, which will use robots to both enhance infection control and solve an acute shortage of workers. They will also apply artificial intelligence to monitor MEP systems and enable predictive building maintenance. “The deep-learning machine embedded in the robots will analyse operating data to check the condition of the equipment,” he explains. “If part of the plant system seems to be in poor condition, the building management system will alert the engineering staff and help them locate the problem so it can be fixed, avoiding any interruption in services.”

At Bon Secours Mercy Health, a healthcare system with 35 hospitals across the eastern US, director of infrastructure Jonathan Hunley is creating a standard sequence of operations that will be used across all of its facilities, including a “pandemic mode” setting to turn an entire emergency department into a negative air environment. For a new hospital in Virginia, he intends to go a step further. “We are looking at taking all these different smart technologies – building automation, power, lighting, nurse call, patient logistics, security – and combining them into one system where I can monitor everything in real-time. I want to get to the point where I can monitor indoor air quality, and put different control sequences into motion if we see anything spiking.”

During COVID, the ability to modify facilities quickly and efficiently has been found to be a very important part of resilience (we discussed building flexibility in detail earlier in the series). In a hospital where spaces are highly specialized, physical changes have complex repercussions. A technological overlay, on the other hand, is far more adaptable.

In Queensland, there is a shift to replace televisions in patient rooms with a “bring your own device” policy, supported by a free high-speed wifi network. “You can do FaceTime, Netflix, GoToMeeting, Zoom, or you can open up the Queensland Health app, put your patient number in, and get access to different services or order your meals,” says Wall. This provides a better patient experience, so aiding recovery, he adds, but it also allows new services or information to be added from a central hub. Ditto digital signage – it’s much easier to change routes through a hospital by reprogramming displays and wayfinding apps than having to manually alter every sign.

But technology’s single greatest contribution to resilience may come down to the way it can make the complex flows within a hospital far more transparent.

At Sydney Adventist Hospital, the largest private facility in New South Wales, passive RFID tags like those used in logistics or retail are affixed to patient IDs and medical devices. This allows clinical staff to follow patients’ treatment journey on a digital display, and rather than nurses having to manually enter the time of a patient event – such as being wheeled in or out of surgery – an accurate reading is automatically added to their electronic medical record. “You can view this through the lens of resilience, but really it’s about efficiency, management visibility and staff empowerment,” says Barbara MacKenzie, who oversaw the project as IS operational and infrastructure manager for Adventist HealthCare. “In stage 2 theatre recovery, they loved it because they could see exactly what was coming at them. In the emergency department, they loved it because when someone came in and asked where their mother was, they could glance up at the board and say ‘she’s in radiology right now – no, actually she’s on her way back down in the lift’.”

The next level would be to build intelligence into the system. In an ideal world, clinicians too would be tagged, though this is a sensitive issue for the workforce. “When you know time and place for people and objects, you can infer a lot of information and start to build a tapestry about what’s occurring,” says MacKenzie. “From the fact that a patient is in that bed at that time, you can infer that an activity is happening or should be happening. You could see that there has been a nurse with them for five minutes, and an IV pump . Or that no one’s been near them for 40 minutes, so you could alert that it’s time to check on them.” 

In the future, machine learning and artificial intelligence could support better decision-making in real time – for example, by matching patient requirements to staffing capacity. “The system could then say that a patient should be sent to bed 14 on ward 2 after surgery, because nurses one, two and three have a particular skill set and the cardiologist is going to be there,” says Roneel Singh, director of technology systems at WSP in Melbourne. “If several nurses call in sick, the rostering and facilities systems could together work out whether some beds should be closed down or how staff could be rotated.”

He believes that the strongest resilience will come from combining data from many different systems – clinical, administrative, building – into a “three-dimensional” database. “There is amazing technology in hospitals but very rarely is it applied holistically or used to solve problems across the entire facility. It’s that extension of the data that we need. Data resilience is about setting up a workflow that could help people who are already under an immense amount of pressure to make some of those clinical decisions.”

All of this will only be possible if the technology itself is resilient. There are no shortcuts, says MacKenzie. “The smart technology is the icing on the cake and it will only be resilient if every single layer in the technology stack is in good working order. A digital hospital is only as good as its connectivity.” In her new role as CTO at Healthscope, a private hospital provider with 43 locations across Australia, she is starting from scratch again to build “digital ready” infrastructure. She groups the components into the core, connectivity – cabling, transport layers, network – and the user experience. The network needs to be a single, converged entity, with redundancy, high availability, security and no unmanaged devices or entry points.

Older, legacy equipment makes all this harder to achieve, but it’s not insurmountable. The network core must be modern enough to support software-defined networking, which replaces physical boundaries with virtual management. This trend has commoditized the hardware itself: “So instead of two big expensive pieces of equipment, you can now have half a dozen that are much less expensive, with a highly capable software layer.” Upgrades can be targeted at the weakest points, and the older, dumber components moved out to the edge of the network.

Healthcare networks cannot afford to have any weak spots, warns Terri Govang, WSP’s director of strategic security + technology. It may be costly to rewire a building or install new conduits, “but mitigation costs pale in comparison to the total cost of a data breach, especially if that breach includes patient information. There is nothing more personal than that.” According to software company Emisoft, 764 healthcare providers in the US were subject to a ransomware attack in 2019, part of an “unprecedented and unrelenting barrage”. Aside from reputational damage and loss of personal data, a system outage can have tragic consequences in the real world – in September, a German woman died after hackers caused the failure of IT systems at a major hospital in Dusseldorf. The biggest vulnerability is not new systems, but old ones that are obsolete or no longer fit for purpose, something for which public agencies are notorious. When the 2017 WannaCry ransomware attack exploited a vulnerability in older Windows machines, the UK’s National Health Service was among the worst affected organizations worldwide.

There can be no compromise on security – but neither can it be at the expense of the user experience, says MacKenzie. This is critical to success, and access must be fast, easy and consistent across devices. Above all, user interactions with new technologies must work smoothly from day one. “If you roll out something that almost works, people stop using it because it’s too much of a risk. Every single piece of technology or workflow change that is imposed on people, you need to ensure there is value in it for them. Once you’ve built trust through delivering on the technologies’ value proposition, you reach the point where resilience happens as an organization – it’s the people and the digitally enabled processes that together form the resilience.”

Smart technologies only have value if they complement human processes, agrees Nikolaus Varchmin, a healthcare project manager with WSP in Munich. “Very often when we think about technology in healthcare, it’s in terms of either/or – either people or robots – rather than ‘and’. But you only get the benefits if you look at the human factor and the infrastructure together, and you really understand how a hospital functions. We need progress in both directions.”

In other words, technology – and the data it channels – can only support resilience if it supports humans themselves.

During this series, we have explored solutions for increasing resilience in healthcare at a system level, through the flexibility of individual facilities, and by using data and smart technologies. But there’s another kind of resilience that trumps them all: human resilience. The ability of people and communities to withstand catastrophic events is dependent on many factors, including underlying levels of physical and mental health, the quality of living and working environments, and existing support networks. To improve resilience in this domain, we need to look beyond healthcare, to the places where most of us live: cities. We’ll look at how the built environment can contribute to healthier, more resilient populations in the final part of the series.