Health and Design - Healthcare Challenges in Times of Polycentric Urbanization - Gunnar Hartmann by dialive

Healthcare Challenges in Times of Polycentric Urbanization Gunnar Hartmann

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Healthcare Challenges in Times of Polycentric Urbanization Gunnar Hartmann

A general introduction to the Health & Design series at Anhalt University of Applied Sciences in cooperation with the Cluster of Excellence Image Knowledge Gestaltung at Humboldt-Universität zu Berlin.

Urbanization and Healthcare A Hot Zone for Urgent Attention by Analysts, Providers, Planners and Patients. The key to successful breakthroughs in science is not that diverse actors cooperate in so-called trading zones but that they feel the urgency to do so—driven by the visceral threat of losing a war or of a raging disease such as Ebola. The urgencies of everyday urbanization are many, but they are often invisible, hidden behind veils of politics and opinion. This makes it hard to find an audience for any one of them—the crisis posed by the Anthropocene may be the best example, and healthcare is not far behind. Consequently, we are focusing on health as a topic of considerable urgency for all urbanites—particularly in countries experiencing a contracting welfare state combined with an aging population. Health, sickness, and care form one cluster of the interacting oscillations that are now reverberating through steadily urbanizing countries. In healthcare, it is chronic disease, rather than acute disease, that puts the greatest pressure on urbanization since it requires repetition in its treatment—not just of medical procedures, but also in the use of urban infrastructures, from the physical to the virtual. The polycentric urbanization of Germany is particularly complex: even as the historically central cities have internally dispersed, old dormant settlements have grown to form vast polycentric domains, though rarely for the purpose of improving service. Instead extraneous reasons, such as land price, politics, and entrepreneurship, lie behind polycentric development, resulting in either extreme agglomeration and duplication or its opposite, desertification, as in cases of regions with no hospitals. In turn, this has fueled a new urgency for solutions—with urbanization now viewed as the constant repair of collateral damage from relentless change. Under the rubric of Bild & Handlung, the research group under which umbrella these publications are published has collected research from the entire analytical force field— from narrative to gravity models—to propose the humble beginnings of a trading zone. Prof. Alfred Jacoby Prof. Dr. h.c. Lars Lerup Dr. Gunnar Hartmann

Healthcare Challenges

in Times of Polycentric Urbanization Existing healthcare systems rely on the logic of centralized organization, but in an increasingly polycentric urbanization, tomorrow’s networks will necessarily be decentralized, distributing primary care and medical services to multiple centres.

Western Europe is currently in the midst of an unavoidable paradigm shift. An increasingly aging population means more patients, a proportional rise in chronic diseases, and increased demand for constant medical care. The medical treatments that such diseases require, however, rely only partly (if at all) on the current hospital of clinical medicine1 (the workhorse of the early welfare state). At the same time, more and more treatments (e.g., immune therapies, hemodialysis, etc.) are becoming more costly, driving particular hospitals that are essential for the provision of primary care out of the market.2 Healthcare systems based on the theoretical uniformity of the welfare state will soon be unaffordable for societies like those in Western Europe. Further, the simultaneous demographic change will redistribute the population, transforming the current urban landscape. Existing healthcare systems rely on the logic of centralized organization, but in an increasingly polycentric urbanization, tomorrow’s networks will necessarily be decentralized, distributing primary care and medical services to multiple centers. This immediate future challenge is leading policymakers to question 1 Clinical medicine refers to patient-related medicine instead of theoretical medicine that is part of basic clinical research. 2 “The prices for medical services rise more slowly (0.2-1.5%) than the costs incurred (2.5-3.5%). [...] Unfortunately, those hospitals driven out of the market were not those that needed to be closed, but those hospitals and clinics that happened to be under bad leadership.” Karl Max Einhäupl, “Bis alle Kliniken insolvent sind,” Handelsblatt, no. 24 (February 4, 2015): 4–5. (Author’s translation.) Einhäupl is the head of the Charité – University Hospital Berlin.

a wide variety of values and assumptions currently in place regarding the role of patients,3 doctors,4 and care providers. In effect, the current healthcare infrastructure must be rethought—above all in its spatial organization, a subject that is at the center of this paper.

Hospital Care

Currently, half of the 2,000 hospitals in Germany suffer financial losses, and almost a sixth of them run the risk of insolvency.

Currently, half of the 2,000 hospitals in Germany suffer financial losses, and almost a sixth of them run the risk of insolvency.5 About 200 hospitals were closed in Germany last year.6 With 8.3 hospital beds per 1,000 people,7 the country is currently oversupplied. This means that many of the remaining hospitals are inefficient due to unused capacity—of the 500,000 hospital beds in Germany, 110,000 beds remained empty each year on average.8 However, today’s actual problems are much bigger than these numbers convey, since the statistics that produced them rely on a spatial model defined by physical distance. If one maps out these deficiencies in the form of a spatio-temporal map (i.e., a space of stim and dross),9 a spiky world of difference appears. 3 “A patient-centered model in medicine leads to patient-oriented research, which focuses on the individualization of results. Thus, treatment effectiveness is assessed by comparing subgroups of patients to individual patients. The goal is to identify which treatment options are more effective for which patient.” Harun Badakhshi, “Patient-oriented medicine, an urge?” talk presented at the Symposium for Health & Design, Villa Vigoni, Italy, 2013. 4 “While patient-centered care favors shared decision-making, patient-oriented research emphasizes outcome evaluation. Doctors evaluate patients and their disease through analyses of heterogeneity (subgroups identified a priori) and disaggregation, the study of differences.” Ibid. 5 Karl Blum, Sabine Löffert, Matthias Offermanns, and Petra Steffen, Krankenhaus Barometer: Umfrage 2014 (Düsseldorf: Deutsches Krankenhaus Institut, 2014), 104–114. 6 Ibid. 7 Statistics are from the Organisation for Economic Co-operation and Development (OECD), quoted in Handelsblatt, no. 24 (February 4, 2015): 4–5. 8 Ibid. 9 “In a world dominated by time rather than space, a distinct separation between activity and inactivity appears. This bifurcation is a fundamental aspect of modern life where 24/7 is but an unattainable ambition for the living and is at this point dominated by artificial intelligence—computers never sleep. Stim as in stimulation while dross refers to inaction, nothingness or sleep.” Lars Lerup, “Stim & Dross: Rethinking the Metropolis,” Assemblage 25 (1995): 83–101.

The hospital, attempting to become more efficient while at the same time keeping pace with clinical innovation, has already started to rework itself from the inside. The hospital’s departmental structure of clinical medicine is currently transforming itself more drastically and more frequently than it has ever done in its history. With further medical and genetic discoveries ahead, we can anticipate an explosion in the catalogue of accessible disease-related signs, requiring the redefinition of existing disease classifications. In turn, this will alter disease descriptions such that physicians can become more specific in their treatment of patients. The time is approaching for customized medicine. At the same time, we anticipate a rise of further medical specialty departments and associated subspecialties, continuing the last century’s trend of exponential growth in clinical departmentalization. This upcoming increase in diversification is likely to be far more extensive than the specialization process started by the implementation of clinical microbiology at the turn of the previous century. The appearance in the late twentieth century of multidisciplinary departments as another kind of clinical specialty is an indication that clinical medicine has already begun to spatially reorganize the hospital’s practice. The adoption of multidisciplinary specialty departments eventually will restructure current clinical medicine. Indeed, the growing pains are already being felt in the inefficiency of the hospital’s multiple workflows— today the biggest economical burden on clinical medicine. The hospital environment now depends on its growing multiplicity of treatment capabilities and increased knowledge, but it is finding that the resulting complexity is reducing its operational efficacy. To minimize operating costs, attempts have been made to maximize the efficiency of these ever more specialized clinical services. Yet such optimization addresses departmental flows rather than treatment flows, e.g., treatment facilities or patient beds are still developed in spaces separate from the diagnostic area of a given specialty. However more streamlined these diagnostics have become, the fact remains a hospital is a complex adaptive system that derives little benefit from such superficial improvements. Instead, an actual hospital consists of “a number of people who are making dayby-day, even minute-by-minute, decisions that impact hospital-wide patient flow, and they are making these

decisions without access to information about what is going on in the rest of the hospital. So they may be optimizing flow within their microsystem, just within their own individual field of play.”10 Space has become a problem of mobility. It is the manageability of clinical practice that is in question here: "Evaluations must be multidisciplinary, and they must address themselves to comprehensive and fully completed processes or outcomes. What difference does it make to a patient, for example, that the test has been completed if the physician has not yet been able to use that information in making a recommendation for action to resolve the patient’s health issue? Patients’ perception of “value” comes with the belief that they were treated for their problem, that their problem was effectively addressed. The test itself is not the value. From this perspective, services should be coordinated and pulled to the patients to produce the value outcome they expect to receive. This pull concept requires us to challenge every departmental boundary and to look at patient movement as a rationalization of service efficacy, as the value stream, and as the key to mending our currently broken commitment processes."11

To overcome silolike departmental thinking requires shifting the focus to the workflows of patient treatments. These workflows move patients, doctors, staff, and materials through, in, and out of various departments. However, each actor is operating according to an individual clock

To overcome silo-like departmental thinking requires shifting the focus to the workflows of patient treatments. From this perspective, each treatment represents a distributed workflow incorporating various departmental activities. These workflows move patients, doctors, staff, and materials through, in, and out of various departments. However, each actor is operating according to an individual clock (Figure 1).

Rethinking the Hospital As the current length of patient hospitalizations shortens, the hospital is increasingly shifting toward providing services to outpatients. With the patient’s home more and more often replacing the hospital ward, the hospital requires fewer patient rooms with sickbeds, and so instead is beginning to offer a greater variety of treatment rooms (so different that they might no longer remind the patient of the hospital). For example, the 10 Kirk B. Jensen, MD, MBA, FACEP, Chief Medical Officer for BestPractices, Inc., quoted in David Chambers, Efficient Healthcare: Overcoming Broken Paradigms (Houston: Rice University Building Institute, 2009), 21. 11 Ibid., 17–18.

Figure 1. Waiting Time

concept of the waiting room (at present a space primarily meeting the needs of doctors and clinical staff) will have to be completely rethought—not so much on the basis of pure efficiency, but more in light of adding value for the patient and the accompanying family members while they wait (e.g., incorporating a variety of choices for patients and visitors alike). New care models are already under consideration, some of which favor patient-oriented care, leading to an increased pressure to redesign the current hospital infrastructure.12 As for the hospital, it will most likely continue its long process of transformation from the concentrated place it once was to something that resembles an open network. Hence, the hospital will soon be unable to treat patients in line with its own research demands (i.e., for studies of individual genes and behavior in addressing cancer-related risk factors), rather than focusing on the demands of the patient (i.e., cancer eradication by surgery, radiology, or chemotherapy). The hospital will therefore need to change so it can act as an innovative hub, establishing various spinoff clinics and centers throughout the city and the region. Thus, various subspecialties that can operate more cost-efficiently in the private sector, as well as those diagnostic departments that focus on early detection, will be outsourced; the hospital’s remaining nursing wards will close, due to an overcapacity of such services within the city; and the hospital will introduce greater flexibility in its internal departmental structure to meet the demands of research needs at an ever-faster pace (and thereby will find itself subject to a continuous redesign processes).

While the healthcare model of the twentieth-century welfare state allowed economies of scale by providing standardized and repetitive care for large populations and so served patients at relatively low cost, the future healthcare model will rely on customized and participative care (particularly in the realm of chronic diseases).

While the healthcare system will follow the same logic of decentralization, it will also accommodate many more actors. The city will become the new market of prevention and care. While the healthcare model of the twentieth-century welfare state allowed economies of scale by providing standardized and repetitive care for large populations and so served patients at relatively low cost, the future healthcare model will rely on customized and participative care (particularly in the realm of chronic diseases). Hence, the patient will be asked to engage. Because this new “active patient” role first needs to find 12 The responsibility of the federal states needs to shift toward the federal government or, as it has been argued, should be given to the actual payers of medical services, i.e., the health insurance companies.

Population Change 2002â&#x20AC;&#x201C;2020 Sharply decreased

Aging Very strong

Decreased Stable

Strong

Increased Sharply increased

Average

Figure 2. Decline of Population and Demographic Aging in Germany

acceptance by doctors and patients alike, this transition between healthcare models will be a gradual, soft transformation. The result will be a new geography no longer concentrated on cartographic information but on what we call time-geography (Hägerstrand).13 Any open (polycentric) network operates on several scales, going from the scale of a building to that of the region. Since our expertise concerns spatial matters, we will attempt to evolve models that point in the direction of a better distribution of resources (Figure 2). Given that this new geography of healthcare services, distributed throughout various small-scale urban fabrics, will remain largely invisible, navigation is required: to rethink our actions according to time-geography demands that we map time. Consequently, images will become of increasing importance as an image-guided navigation will steer our movements through space.

To rethink our actions according to time-geography demands that we map time. Consequently, images will become of increasing importance as an image-guided navigation will steer our movements through space.

Long-term Thinking To envision time remains a difficult task. Therefore, we tend to rely on metaphors. Tim Hawkinson’s artwork Spin Sink visualizes time as something other than the familiar clock (Figure 3). His sculpture consists of twenty-four interlocking gears that are powered by its tiniest gear, which spins at 1,400 revolutions per minute.14 This fast-speed motion decreases from one gear to the next and, in a linear fashion, from left to right. While it is impossible for the observer to perceive the individual motion of the first fast-moving gears, it is equally impossible to grasp any of the motion of the last slowmoving gears. Hawkinson’s century clock demonstrates how limited the range of our human visual perception is and how dependent we are on mental images that steer our conceptualization of reality. In this context, the mathematician and physicist Freeman Dyson suggests that we should view time in terms of six distinct time scales: "The destiny of our species is shaped by the imperatives of survival on six distinct time scales. On a time scale of years, the unit is the individual. On a time scale 13 For a more thorough discussion on the concept of timegeography see the following publication. Lars Lerup, Polycentric Urbanization: Image & Action (Dessau: Health & Design series at Anhalt University of Applied Sciences, 2015). 14 Lawrence Rinder, Tim Hawkinson (New York: Harry N. Abrams, Inc., 2005), 38-39.

Figure 3. Spin Sink

of decades, the unit is the family. On a time scale of centuries, the unit is the tribe or nation. On a time scale of millennia, the unit is the culture. On a time scale of tens of millennia, the unit is the species. On a time scale of eons, the unit is the whole web of life on our planet. Every human being is the product of adaptation to the demands of all six time scales."15 The present age, one during which humanity has adversely affected the planet by altering its climate, depleting its resources, and eroding its biodiversity, demands long-term thinking; it challenges us to find systemic approaches. As the ecologist Stewart Brand has suggested, we ought to view the process of civilization holistically, as existing in various layers that are coevolving at different paces. Once we do that, we begin to see the process of urbanization as a self-regulating, nonlinear corrective—partially stabilizing and partially contradicting current conditions. Brand’s cross section depicts the differing paces of the various layers of a healthy civilization, whereby the fast parts, like fashion and commerce, propose ideas and absorb shocks, while the slow parts, like governance and culture, set the rules, maintain continuity, and integrate lessons (Figure 4). “The whole combines learning with continuity.”16 Let us then apply Brand’s tool on an architectural scale and return to the hospital. As one of the most innovative places in the nineteenth-century city, the hospital of clinical medicine provided an environment for the development of a complex array of technological tools and a variety of specialized clinical techniques. Thus, medical practitioners needed the hospital if they were to treat patients in light of this expanded knowledge of the body’s complexity. To reach today’s high level of innovation, the practice of clinical medicine relied on both diversification and division of labor. Only by means of clinical specialization was medical innovation possible, which in turn enabled physicians to scientifically diagnose and treat ever more diseases. The phenomenon of specialization in clinical practice can be viewed as a bundle of interrelated processes. Sorting different processes (as Brand suggests) according to their pace of specialization allows one to draw a cross section through medicine’s more general 15 Freeman Dyson, From Eros to Gaia (New York: Pantheon, 1992), 341. 16 Stewart Brand, The Clock of the Long Now (New York: Basic Books, 1999), 37.

Figure 4. The Order of Civilization

process of specialization (Figure 5, top).17 Processes that specialize at a fast pace, like clinical research and treatment, propose and integrate ideas, while processes that specialize at a slower pace, like departmental structuring and clinical infrastructure formation, establish regulations and affirm persistence.18 While the fast-changing processes are prominently reflected within the medical discourse, the slower-changing processes dominate clinical practice. As specialists limit their scope of operation, this narrowed focus requires greater concentration, which means clinical specialties seek a space that allows both for focus and for the unfolding of specialized skills. Those clinical specialties that do not depend on proximity to the patient have an advantage since they can appropriate a variety of spaces far from the sickbed, while the plan of the hospital building remains unchanged. These claims on space distant from the patient develop gradually, with spatial practices going through a process of adaptation in response to new conditions and requirements. Let us consider a few examples. Perhaps one of the least disruptive adaptations of a spatial practice is the reuse of an already existing space. Thus, an existing work desk inside a clinical laboratory might be reserved for a newly emerging diagnostic technique, or a certain number of sickbeds might be assigned for a newly developed clinical therapy. The newly established work desk as well as each newly designated sickbed requires the assigning of particular clinical staff to it. If the added work produces relevant results, the reserved work desk might soon demand a work area, and the rooms with the assigned sickbeds might gradually turn into a specialized subdivision or ward. It is only then that actual alterations to the existing space plan would be needed. That is, partitions with doors might be erected to allow for partial visual or acoustical seclusion of the work area, or in the case of the specialty ward, the same doors might intersect corridors. Such doors might be changed to allow uncensored unidirectional access (by providing a door handle only on one side) or fully controlled access (by requiring a key or magnetic card). The example of the partition’s door demonstrates how what was once a simple passage can be turned into a control element, administrating access and consequently regulating 17 Stewart Brand’s diagram “The Order of Civilization.” Ibid., 34–39. 18 Ibid.

Clinical Research Clinical Treatment Departmental Structure Infrastructure

Partition Wall Room Ward Building Urban Block

Figure 5. Pace Layers of Clinical Specialization

workflows. In a larger perspective, these partitions (walls and doors) mark the territorial claims of clinical specialties. By redesigning the existing space plan of the clinical infrastructure, these seemingly ephemeral partition devices in fact reorganize the clinical workflows and therefore affect (invisibly) the existing spatial relations within the hospital. Therefore, we can view the process of clinical specialization as a constant adaptation of movement. Such a reconfiguration of workflows gradually reorganizes the hospital and eventually bears a large share of responsibility for the rapidly diversifying clinical culture, whose daily routines digress, clinical practices deviate, and medical terminology differs widely. What eventually results from clinical specialization is spatial change, as the hospital’s infrastructure spatially transforms and expands over time. By observing the process of spatial change from the same perspective that was previously used to study the phenomenon of specialization in clinical practice, we can view the transformation of the clinical infrastructure as a bundle of interrelated processes. Again, different spatial elements can be sorted according to their pace of change, which allows one to draw a cross section through the hospital’s general process of spatial change (Figure 5, bottom).19 Some spatial elements change at a faster pace (like adding partitions and walls to define hospital rooms), while other transformations occur at a much slower pace (like additions to the hospital building itself and the urban block). We should emphasize, however, that even the fastest-changing spatial elements are extremely slow compared to the far more rapid pace of clinical specialization. For example, a room absorbs and integrates spatial partitions over time, i.e., a partition wall might be seen as the precursor for a solid wall that will replace it. And adding new work or dividing existing labor within a department, which is in itself a spatial claim, leads to more or less spatial densification. But the fact remains that a room cannot be divided ad infinitum. Therefore, whereas the process of clinical specialization has parallels with departmentalization and also resembles a process of spatialization, the creation of new spaces is strictly the outcome of a process of divergence and division within clinical practice.

We can view the process of clinical specialization as a constant adaptation of movement. Such a reconfiguration of workflows gradually reorganizes the hospital and eventually bears a large share of responsibility for the rapidly diversifying clinical culture.

These incremental changes in clinical practice are brought on by a variety of actors. Each is operating according to an 19 The diagram is based on Stewart Brand’s diagram “The Order of Civilization.” Brand, The Clock of the Long Now, 34–39.

Place-Time is a mapping technique that illustrates time on top of geographic information. TimePlace, on the other hand, is mapping time rather than distance.

individual clock. To coordinate and assess changes that continuously unfold at different paces over time requires new analytical tools. It is therefore not enough to merely record spatial changes in order to assess this complex phenomenon. Instead, the consequences and impacts these spatial changes have had on various workflows of patient treatments need to be evaluated as well. That is, workflows demand to be mapped in place and time.

Mapping Time When asked to represent time, we choose a line. The timeline seems as if it has always been there, yet such a simple device—one that visualizes historical events along a single axis—is a rather recent invention (roughly 250 years old).20 However, “the fact is that spatial form is the perceptual basis of our notion of time, [and] we literally cannot ‘tell time’ without the mediation of space.”21 The basic measures of events in the past (history) were place (geography) and time (chronology). What we call Place-Time is a mapping technique that illustrates time on top of geographic information. Hence, while places are mapped according to their physical distance from each other, time is superimposed by other graphic means. TimePlace, on the other hand, is mapping time rather than distance. Since the time to travel may vary according to the mode of transportation and the route chosen, the time it takes to get from one place to another sets the two places in different positions on a Time-Place map. In the following, we will explore briefly a few such mapping examples.

Place-Time Let us consider one of the perhaps most widely known place-time maps in history. The cholera outbreak during the summer of 1854 in central London provided the case study that an English physician by the name of John Snow had been waiting for. To him, cholera displayed symptoms of a bodily (i.e., gastro-intestinal) disease, since he had analyzed cholera according to traces that the disease left inside the human body. Consequently, he concluded that the disease could not have arrived by air, 20 Daniel Rosenberg and Anthony Grafton, Cartographies of Time: A History of the Timeline (New York: Princeton Architectural Press, 2010), 14. 21 W. J. T. Mitchell, “Spatial Form in Literature: Toward a General Theory,” in The Language of Images, ed. W. J. Mitchell (Chicago: University of Chicago Press, 1980), 274.

Figure 6. Broad Street Pump Cholera Outbreak of 1854

i.e., caused by something that one might have inhaled; the carrier had to be something swallowed. Being a proponent of the germ theory, Snow entered the cholera scene with that theory in mind and so suspected drinking water as the contaminated source. Waterborne germs were hard to prove at that time. In the upcoming era of the natural sciences where empirical evidence would be a prerequisite, convincing somebody of the existence of an invisible germ was unlikely. As if that were not enough, the theory that “all smell is disease” further prejudiced most scientific minds and measures.22 Snow needed a new approach. So he started a map that combined time and space—attempting to make visible an otherwise invisible pattern. Snow’s map redrew the neighborhood according to actual walking time (like a Voronoi diagram, where a plane is partitioned into regions based on distance to points in a specific subset of the plane),23 and it reorganized the death toll data according to specific street addresses. Instead of observing the phenomenon of cholera’s effects (its fatal attacks and resulting deaths) solely over the vector of time (in the format of a chronological tablet), Snow lined up black bars for each cholera death next to specific street addresses, allowing the data to be read geographically (Figure 6). By reformatting the data, he enabled the space of the epidemic outbreak to appear. That, in turn, drew attention to a particular water pump on Broad Street, the neighborhood’s preferred source of drinking water. Snow’s map turned out to be significant later on, even if it did not have an immediate impact.24 22 In his 1846 testimony to a parliamentary committee investigation of the problem of London’s sewage, the sanitation commissioner, Edwin Chadwick, stated: “All smell is, if it be intense, immediate acute disease; and eventually we may say that, by depressing the system and rendering it susceptible to the action of other causes, all smell is disease.” Steven Johnson, The Ghost Map (New York: Riverhead Books, 2006), 114. 23 https://en.wikipedia.org/wiki/Voronoi_diagram (access 2015). 24 “As the waterborne theory of cholera became increasingly accepted, the map was regularly invoked as a shorthand explanation of the science behind the theory. It was easier to point to those black bars emanating ominously from the pump than it was to explain the whole idea of microorganisms invisible to the human eye. The map may not have had the impact on its immediate audience that Snow would have liked, but something about it reverberated in the culture. Like the cholera itself, it had a certain quality that made people inclined to reproduce it, and through that reproduction, the map spread the waterborne theory more broadly. In the long run, the map was a triumph of marketing as much as empirical science. It helped a good idea find a wide audience. ” Johnson, The Ghost Map, 198–199.

Figure 7. Map of Melbourne and Environs Minimum Railway or Tramway Time Zones (top) and Cardiac Isochrones Positioning System (CIPS) (bottom)

In hydrology or transportation planning, an isochrone plan defines an area of reachability at a set time, i.e., an equal travel time. In medicine, cardiology also makes use of isochrone images “to visually detect abnormalities using body surface distribution.”

Another example of a place-time map is an isochrone plan or diagram. In hydrology or transportation planning, an isochrone plan defines an area of reachability at a set time, i.e., an equal travel time (Figure 7, top). In medicine, cardiology also makes use of isochrone images “to visually detect abnormalities using body surface distribution” (Figure 7, bottom).25 Also Google offers a service called Mapnificent, which shows one the urban areas one can reach by public transport from a particular chosen point at a set time.26 Further examples of isochrone maps are the GIS studies performed by Lothar Koppers at Anhalt University that show the time constraints of reaching various destinations. Both studies attempt to reassess current commuter belts based on travel time. Here, reachability, i.e., the time is takes for a car to travel to an elementary school (Figure 8) or for public transport to reach a particular station (Figure 9), has been superimposed on geographic information. Rather than using a model that assigns a catchment area based on municipal boundaries (Figure 8) or on physical distance (Figure 9), these GIS studies use actual travel time as the guiding operand. That is, isochrones as travel time fields are suggested to redraw previous catchment areas.

25 T. Miyashita and Y. Okano, “Isochrone map, its implication and clinical usefulness,” Nihon Rinsho: Japanese Journal of Clinical Medicine 53, no. 1 (January 1995): 48–55. See https://en.wikipedia. org/wiki/Isochrone_map (accessed 2015). 26 http://www.mapnificent.net (accessed 2015).

Elementary school Settlements Elementary school reachable less than 5 min Elementary school reachable less than 10 min Elementary school reachable less than 15 min Elementary school reachable less than 20 min

Figure 8. How far is it to the school?

Arrival station

Travel time: 0-10 Minutes

Bus stop Station perimeter in steps of 10 km Streets No data

11-20 Minutes 21-30 Minutes 31-40 Minutes 41-50 Minutes 51-60 Minutes

Earliest departure: 07:00 am Latest arrival: 08:00 am Running speed: 5 km/h

The arrival station is from each colored area reachable within the time specified. Figure 9. Accessibility of Station

Time-Place To consider what a time-place map entails, let us start with an isotype by Otto Neurath (Figure 10).27 The diagram “The Journey to America” depicts the impact of transport technology. While the voyage from Europe to America in the 1490s with a sailing ship took approximately 70 days, the same journey in the 1930s with a steamship decreased by 65 days. Neurath displays the diminishing of travel time in pictorial form by the number of waves, i.e., one wave equals one day. Over the centuries, by analogy, the two continents moved closer together. If we were to add today’s travel time to Neurath’s distance ratio, America and Europe, again by analogy, would require simply a bridge to connect them. What this diagram illustrates on a global scale applies also to the city and its hinterland. Commuter rail lines, high-speed trains, freeways, ring roads, subways, etc., all have reshaped familiar geographies of distance.

The increasing dispersal of healthcare services over vast urban territories prefigures what we have called The Region as Hospital. Hence, slowly but surely the hospital’s function will spread out to remix with our neighborhoods.

However, as we venture in this way into a new pictorial language of time, all of a sudden we are dealing with a dynamic entity. Exemplary for such time-place maps are the so-called TimeMaps by Vincent Meertens (Figure 11). Rather than superimposing time graphics on geographic information, this map app redraws a geography according to the time it takes to travel from one place to another within the Netherlands. One sets a starting point and time (the nearest train station is automatically assigned), while the app renders a map according to the travel time to various destinations. The generated map is based on a series of 30-minute rings, which are represented in radiant colors reaching from green to purple. While the country appears rather small when seen from the perspective of well-connected larger cities (since travel time is relatively short), the same country seems quite large from the perspective of less frequently connected towns. The map expands or foreshortens depending on the time of the day or on other factors that might impact travel time.28 The increasing dispersal of healthcare services over vast urban territories prefigures what we have called 27 A so-called isotype stands for International System of TYpographic Picture Education. 28 “Because of the good infrastructure in the Netherlands, distance becomes irrelevant. In our busy lives today we think in terms of time instead of distance. So the current maps as we know it are obsolete.” Vincent Meertens, see http://www.vincentmeertens.com/ timemaps/ (accessed 2015)

1492 1800

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Figure 10. The Journey to America

The Region as Hospital. Hence, slowly but surely the hospital’s function will spread out to remix with our neighborhoods. The treatments of chronic diseases that are irremediable, like dialysis, clearly represent one of the burdens that an aging society’s healthcare system has to bear. Further, the distribution of treatment sites (e.g., the distribution of dialysis machines) allows for insights into the challenges of healthcare delivery in times of polycentric urbanization. That is, dialysis and other chronic treatments are at the forefront of polycentricity. As clearly shown in the kind of work using Geoinformatics being performed at Anhalt University, mapping various services according to their travel time begins to clarify the complexity of the tasks ahead. Once we add to this model the data on population distribution, a highly efficient redistribution of medical services could result. To implement such a potentially radical redistribution of healthcare facilities is another complicated matter.

Distributed healthcare requires new bindings of time and place that make the navigation through the urban environment possible.

The move toward a polycentric time-geography presents many operational complexities, as suggested above, on several scales. While today’s hospitals appear as bundles of highly concentrated building complexes on the urban scale, the same hospitals are governed by polycentricity (departmentalization) on the building scale. Polycentricity on the regional scale is already present in Germany, going far back, as elaborated by Christaller in his place-theories. The complexity of finding the right place for any service function is dependent of demography, the medical needs of the patients served, distance and time from home to service, transportation capabilities, market constraints, and service operations. Such a complex equation can only be achieved by increasing communication among the various actors. Distributed healthcare requires new bindings of time and place that make the navigation through the urban environment possible.

Navigating through the Environment The concept of ubiquitous computing, i.e., the idea of embedding technology into the background of everyday life, imagines a world of computing without computers. That is, ubiquitous computing aims to simplify and distribute the computations typically handled by discrete machines: "Mark Weiser’s Ubiquitous Computing project, at the

Figure 11. Time Maps

Xerox Palo Alto Research Center in the early 1990s, provided one of the first convincing glimpses of [an electronically mediated environment]. Within the interior space that Weiser created, office workers wore wireless transponder pins that allowed a computer to track their locations. The environment was populated with wearable, handheld, and part-of-the-furniture display and interaction devices. These devices were all interconnected to create a single, dispersed, interactive interface. The inhabitants became, in effect, living cursors; information that they needed automatically followed them from place to place, and showed up on whatever display device happened to be convenient at the moment. And the building always knew, from moment to moment, exactly where to forward their phone calls and their email."29 When powered by tiny, cheap microprocessors, the built environment would become part of a computing network—the Internet of Things (IoT). In the age of sustainability, buildings have already started to “communicate” with their immediate environment, e.g., they incorporate an array of sensors that allow them to monitor various atmospheric data, like internal and external temperatures, ambient light levels, outdoor weather conditions, air circulation, etc. As buildings increasingly become a part of an IoT, the change will add a variety of attributes to the conventional architectural elements of floor, wall, door, window, etc. Embedded technology will allow these elements not only to communicate whatever they sense or measure, but also to interact with the environment: they will not only collect data but also process this data to inform our behavior in the built environment (Figure 12).

A virtual navigational space that adapts quickly, leads the way, steers around congestions, tracks positions, reminds and updates time schedules, and simulates choices. Fed by data from multiple handheld devices, this virtual space would allow for communication among all actors and for the physical space to learn and eventually adapt faster.

Let us return to the hospital once again, where workflows move patients, doctors, staff, and materials through, in, and out of various departments. Such cross-departmental circulation streams through an assemblage of multiple common zones, e.g., waiting rooms, lobbies, corridors, vestibules, staircases, elevators, walkways, and service roads. These spatial zones are the connecting tissue that allows a distributed space to form. We just need to add to these mutual paths a virtual navigational space that adapts quickly, leads the way, steers around congestions, tracks positions, reminds and updates time schedules, and simulates 29 William J. Mitchell, e-topia: ‘Urban Life, Jim—But Not as We Know It’ (Cambridge: MIT Press, 2000), 60.

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Fig. 12. Sensors for the Networked Environment

choices. Fed by data from multiple handheld devices, this virtual space would allow for communication among all actors and for the physical space to learn and eventually adapt faster (Figure 13). Just as cars, telephones, and cell phones slowly erased the importance of visible geography, patient handhelds will deemphasize the need for spatial clarity as communication replaces the built environment. The virtual space will help to overcome the discontinuity of polycentric dispersion. In other words, if you equip patients or medical staff with handheld devices that incorporate location and orientation sensors, the device will not only help them navigate through the physical environment but also map those actions according to place and time. That is, a networked environment allows for a constant exchange of information among various actors, objects, and the environment. Hence, actions are interlinked to navigational map devices (Figure 14). Their interaction with the environment in real time steers behavior. Rather than striving for mere efficiency in healthcare services, a networked environment will offer multiple choices to patients, e.g., by providing more transparency through real-time updates on treatment schedules, reminders on when to be where, and options on which path to choose, where to wait, and what mode of transportation to take, etc.

Familiar hospital functions will remix gradually within our neighborhoods. Rather than being stored in one place and accessible to only one party, patient data easily flows to new intermediate access points.

However, certain data (especially in the case of a medical emergency) is only of value if it arrives on time. It therefore comes as no surprise that one of the first practical paging services originated within the medical sector.30 Today, to be on call is no longer a privileged position held by physicians. In fact, when fully integrated (i.e., when everyone is able to receive and send data), patients as well as medical staff will become part of a dynamic image. Made possible by continuous electronic monitoring as well as personalized status reports, such an image will increasingly inform other subsequent actions. As a result, the virtual environment substitutes for the physical as an information field: "In the twenty-first century, then, we can ground the 30 â&#x20AC;&#x153;One of the first practical paging services was launched in 1950 for physicians in the New York City area. Physicians paid $12 per month for the service and carried a 6 oz (200 g) pager that would receive phone messages within 25 mi (40 km) of a single transmitter tower. The system was manufactured by the Reevesound Company and operated by Telanswerphone.â&#x20AC;? https://en.wikipedia.org/wiki/ Pager#History (accessed 2015).

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condition of civilized urbanity less upon the accumulation of things and more upon the flow of information, less upon geographic centrality and more upon electronic connectivity, less upon expanding consumption of scarce resources and more upon intelligent management. Increasingly, we will discover that we can adapt existing places to new needs by rewiring hardware, replacing software, and reorganizing network connections rather than demolishing physical structures and building new ones. […] Physical settings and virtual venues will function interdependently, and will mostly complement each other within transformed patterns of urban life rather than substitute within existing ones. Sometimes we will use networks to avoid going places. But sometimes, still, we will go places to network."31 In other words, the hospital as a central medical facility providing acute care will not be displaced so much as it will now be accompanied by a variety of local diagnostic and treatment centers, mobile care units, and home care providers. The expansion of the hospital will reach far beyond the hospital campus and into individual homes, the neighborhoods, the city, and the polycentric landscape beyond. Familiar hospital functions will remix gradually within our neighborhoods. For example, instead of depending on one large diagnostic device, multiple smaller devices will cut down redundancy, especially redundant workflows. Clinical practices as well as medical services formerly defined to a particular location (hospital or clinical department) will now be mobile. In fact, various clinical workflows have already dematerialized: medical records previously on paper are now distributed digitally. Rather than being stored in one place and accessible to only one party, patient data easily flows to new intermediate access points. If such patient data can be moved virtually, it is obviously more efficient than physically moving patients or staff. Considering the increase in chronic diseases, electronic distribution of medical services (like telemedicine) will cut down on long and unnecessary trips, as well as help to diminish waiting time, while simultaneously advising and monitoring patient adherence.

While acute care, by the relative uniqueness of each case, is highly dependent on customized care, chronic care is highly dependent on participative care. Both care models will operate within a new geography that no longer will concentrate on cartographic information but on what we will call time- geography.

31 Mitchell, e-topia, 155.

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Coda A fork in the road to quality healthcare has emerged: acute care versus treatment of chronic disease. While acute care is exceptionally successful because of its steadily increasing quality combined with its robust monetization, treatment of chronic disease is always under economic pressure, and patients and doctors suffer symmetrically. Consequently, the pressure to rationalize and automate chronic care is urgent, but it is also being combined with a dramatic push for lifestyle changes, which in turn has repercussions far beyond the hospital. It seems that this separation within healthcare will have a radical influence on systems and infrastructure, since acute and chronic diseases require two different care models. While acute care, by the relative uniqueness of each case, is highly dependent on customized care, chronic care is highly dependent on participative care, especially since it opens a Pandoraâ&#x20AC;&#x2122;s box of additional provisions for diet, exercise, transport, and ongoing care. Both care models will operate within a new geography that no longer will concentrate on cartographic information but on what we will call timegeography.

List of Illustrations Figure 1. Waiting Time. Illustration by the author. Figure 2. Decline of Population and Demographic Aging in Germany. Illustration by the author and Henry McKenzie. Data from “Bevölkerungsabnahme und Alterung,” BBR-Bevölkerungsprognose 2002-2020/Exp. Figure 3. Spin Sink. Lawrence Rinder, Tim Hawkinson (New York: Harry N. Abrams, Inc., 2005), 104-105. Figure 4. The Order of Civilization. Illustration by Stewart Brand “The Order of Civilization.” Reprinted from Stewart Brand, The Clock of the Long Now (New York: Basic Books, 199), 37. Figure 5. Pace Layers of Clinical Specialization. Illustration by the author. Figure 6. Broad Street Pump Cholera Outbreak of 1854. Illustration by John Snow, “Broad Street Pump Cholera Outbreak (1854).” Reprinted from Ralph R. Frerichs, UCLA Department of Epidemiology, School of Public Health, www.ph.ucla.edu/epi/snow. html (access 2015). Figure 7, (top). Map of Melbourne and Environs Minimum Railway or Tramway Time Zones. Reprinted from Melbourne and Metropolitan Tramways Board (State Library of Victoria, 1910-1922). https:// en.wikipedia.org/wiki/Isochrone_map (access 2015). Figure 7, (bottom). Cardiac Isochrones Positioning System (CIPS). “Electrocardiographic imaging-based recognition of possible induced bundle branch blocks during transcatheter aortic valve implantations,” Europace: Oxford University Press, 5 May, 2014, figure 4. http://europace.oxfordjournals.org/content/16/5/750 (access 2015). Figure 8. How far is it to the school? “Wie weit ist es bis zur Schule? (2012).” Lothar Koppers, Volker Höcht, Thomas Weichert and Ulrike Pickelmann, VDVmagazin Bd.63, Nr.4, 2012, 308-311. Figure 9. Accessibility of Station. Illustration by Christian Wolff and Anton Popov. “Erreichbarkeit der Haltestelle: Wolfen, Greppiner Straße (2013).” Reprinted from study “ABW lernt – Wikizapp,” Lothar Koppers (Dessau: Anhalt University of Applied Sciences, 2013). Figure 10. The Journey to America. Illustration by Henry McKenzie. Based on illustration by Otto Neurath, “Die Reise nach Amerika (1932).” Reprinted from Gesellschafts-und Wirtschaftsmuseum in Wien, Technik und Menschheit: Bilder des Gesellschafts- und Wirtschaftsmuseum in Wien Vol. 2 (Vienna: Deutscher Verlag für Jugend und Volk, 1932), plate 8. Figure 11. Time Maps. Illustration by Vincent Meertens, “TimeMaps (2010).” http://www.vincentmeertens.com/timemaps/ (access 2015). Figure 12. Sensors for the Networked Environment. Illustration by Henry McKenzie. Figure 13. Patient Navigation. Illustration by the author and Henry McKenzie. Figure 14. Mapping Navigation. Illustration by the author and Henry McKenzie.

Health & Design series at Anhalt University of Applied Sciences in cooperation with the Cluster of Excellence Image Knowledge Gestaltung at Humboldt-Universit채t zu Berlin