Tonya Somerton BN RN MTM

November 12, 2015

 Introduction
 Purpose/motivation
 Healthcare Technology Assessment (HTA)

 Literature Review
 HTA Models
 HB-HTA Elements
 Decision making criteria in Healthcare

 Research Results
 EH Management Survey
 Discussion
 HTA Improvement opportunities for EH
 Improving Local HTA processes to support Decision Making at
EH
 A HTA decision support tool for EH

 Conclusion
 A Framework for improving HB-HTA
 Introduction

 Literature Review

 Research Results

 Discussion

 Conclusion
Purpose & Motivation
 New Healthcare technologies are introduced
daily
 Available Funding for healthcare is decreasing
 Healthcare organizations must be fiscally
responsible, balancing funds & quality
healthcare
 Responsibility: Assessment & Prioritization of
healthcare technologies.
Healthcare Technology Assessment

is the systematic evaluation of the

properties, effects, and/or impacts of
health technology.

-Hailey, Babidge, Cameron, & Davignon 2010

The role HTA plays is to provide timely evidence to
answer the following specific questions:

◦ Is it safe?
◦ For whom does it work and when?
◦ Is it better than what we already have/do?
◦ Does it provide value for money?
◦ Can we afford it?
◦ Can we afford not to?
◦ What is the tradeoff?
◦ What else needs to be considered?
 Literature review:
◦ Best practice HB-HTA Models
◦ Technology assessment elements & decision-
making criteria
◦ Multi-criteria decision-making frameworks used in
healthcare

 Questionnaire, Interviews, Focus Groups,

CIRC
◦ Current healthcare technology assessment culture,
processes and decision-making criteria used at
Eastern Health
 The hope is that this information can assist
publicly funded healthcare organizations to
perform more effective and higher quality local
health technology assessment and to make
decisions based on evidence and
organizational strategic priorities
 Introduction

 Literature Review

 Research Results

 Discussion

 Conclusion
 HTA is conducted at several levels
◦ Internationally (HTAi, INAHTA)
◦ Nationally (EUnetHTA, NICE, AHRQ, CADTH)
◦ Provincially (IHE, INESSS, OHTAC, NLCAHR)
◦ Regionally (NL RHA’s)
◦ Locally (Eastern Health sites).

 Focus: HB-HTA or/ Local HTA

 In
recent years, increasing
numbers of local level HTA
have been used to support
managerial decision
making.
 HB-HTA emerged as a way for managers to
respond to three environmental “pressures”:

1. The need to improve the level of efficiency and

effectiveness, while operating under budgetary
restraints.

2. The need to be cognizant of the “context”

factor: opportunities and advantages vary based
upon the resources and competencies available
within a healthcare organization’s divisions.

3. The need to push forward scientific evidence to

clinical practice.
-HTAi, 2007
Percentage of Worldwide Organizations using
the recognized HB-HTA Models

23
Internal Committee
3
63 10 Mini HTA
Ambassador
HTA Unit

-HTAi, 2007
 Clearly defined and widely circulated scope of assessment
 A written HTA Organizational Policy
 Unbiased and transparent processes
 Inclusivity of all health technologies to avoid distorted decision
making
 Multiple pathways for technology review
 Clear prioritization systems
 A multi-criteria approach via standardized tools
 Stakeholder involvement
 Acknowledgement of limitations
 Exploration of all available data through multiple tools
 Timeliness and clear timelines
 Communication of findings
 Monitoring of implementation and long term impacts

-Drummond et al, 2008; Alberta Health & Wellness, 2008, Poulin et. al, 2011
 HTA Frameworks
Well developed HTA processes possess the following characteristics:

1. Influence decision making and are trusted as

methods to aid decision making.

2. Influence the adoption and diffusion of technology.

3. Influence health outcomes/efficiency and equity

-Haas et al. (2008)

The rational decision-
making model 1. Define
the
problem
• includes six steps
• describes how individuals 6. Select
should work through the best
2. Identify
the criteria
decisions to maximize the alternative

outcome.

2 mathematical models
that support multi-criteria
decision making: 5. Evaluate 3. Allocate
the weights to
• Analytical Hierarchy alternatives the criteria
Process (AHP) &
• Decision Matrix Model. 4. Develop
alternatives
Poulin et al., Draborg et al, Johnson-Masotti Goetghebeur
2013 2005 & Eda, 2005 et al., 2008
• Health Gain • Clinical • Patient • Quality of
• Service • Economic centered evidence
Delivery • Patient-related • Organizational • Disease
• Strategic Fit • Organizational • External impact
• Innovation • Intervention
• Financial • Economics
 Introduction

 Literature Review

 Research Results

 Discussion

 Conclusion
 Survey
◦ Respondents:
Top 10 rated criterion:

Bottom 5 rated criterion:

◦ Who is responsible for final decisions regarding
Healthcare Technology Purchases?
◦ How often are decisions made regarding health
technology acquisition strategically aligned?
◦ How often are decisions in relation to health care
technologies based on multiple factors such as
patient impact, suitability to all sites, cost and end-
user workload?
◦ How often are frontline employees consulted when
making decisions regarding acquisition of new
health technologies?
◦ Managers and directors were asked how often their
input is sought when decisions about health
technologies are being made that directly impact
their division or program
◦ How often are patients included in technology
acquisition decision making?
◦ How often do issues occur within program with the
implementation or roll-out of a healthcare
technology to other units or sites that result in
requiring additional unanticipated resources such
as people, additional training, other equipment, or
infrastructure.
◦ We asked the participants who indicated that issues
had occurred in their department how much the
issues unexpectedly cost the organization.
◦ We asked the Eastern Health clinical managers
group how often their decision-making criteria are
ranked and scored in a formalized manner.
 Introduction

 Literature Review

 Research Results

 Discussion

 Conclusion
Eastern Health has a great basis for an effective and successful
HB-HTA process.

Their Capital Equipment Plan has been revolutionary to the

organization in providing evidence-based rationale to the
government to validate funding requests.

However, Eastern Health’s approach to HTA and decision making

is not applied consistently throughout the organization, as it is
dependent on multiple factors such as:

• Technology cost
• Funding Source
• Manager/ expert knowledge
 Opportunity for improvement Current conditions at Eastern Health

HB-HTA Model Partially an “Internal Committee Model” processes. The committee is not dedicated to
Health Technologies alone the CIRC reviews all Capital Requests.

Local HTA Advisory Committee Adhoc Program content “experts” pulled in as needed to write tenders. Executive
decision makers based on info from managers who sometimes lack HTA insight.

Clearly define pathways for HB-HTA Multiple pathways, unclear to many. Lacks Transparency

Policy Development No Policy in place

Increase Stakeholder involvement Sporadic Managers and Frontline staff involvement. Patient involvement is very little.

Seek all available data Strata system requires some information collection processes updated. For items under
$4,000 the forms require more detail

Increase assessment comprehensiveness Criteria very limited, scale for scoring not very detailed and not weighted.

Improve Timeliness Process can take a very long time, with very little sharing of updates or status of
request.

Increase Decision-support tools for managers No decision support tools for HB-HTA in use
using a Priority Setting System

Increase transparency of process and results Process and rationales for decisions is unknown to managers and staff.

Evaluation of expected outcomes Evaluation methods unclear

 Healthcare organizations who have access to HTA
experts (i.e. teaching hospitals) should take
advantage of the availability of HTA experts to
form an HTA Unit.

◦ Oversee HTA within the organization;

 providing guidance, evidence, and decision support tools for
the HB-HTA advisory committees who do the HB-HTA; and
 providing recommendations to the executive level decision
makers.

◦ Most expensive of the models but, is the most effective

model on decision making.

◦ $400 million annually on supplies and equipment.

 The addition of local HTA Advisory Committees,
which could be site and/or program specific, could
streamline HTA.

◦ These committees would be made up of representatives

from each site that a program is practiced in or could be
site-specific with representatives from each program.

◦ This decision would have to be made based on discussions

with leadership.

◦ The committees would review requests submitted by

managers and score them based on the strategic priorities
of Eastern Health using standardized decision-support
tools to prioritize recommendations for the executive
decision making team.

◦ These recommendations then would be the result of a team

of professionals.
 Given the current multiple pathways for HTA
identified in my research at Eastern Health, the
recommendation of creating clear pathways for HB-
HTA is essential.
◦ No matter where the technology is identified or no matter
the cost of the technology, the division manager that will be
directly impacted should be contacted to begin the HB-HTA
assessment. Those closest to the impact of the technology
should be involved in the HTA.

◦ At Eastern Health, there is the opportunity to create two

distinct pathways:
(a) a Minor Equipment Pathway for items less than $4,000
(b) a Capital/Major Equipment Pathway for items more than
$4,000.
 A regional policy is necessary to clarify the
expectations and processes of the HTA that
would be undertaken at Eastern Health.

◦ This policy should include all stakeholders, staff,

managers, leadership and patients.
◦ The policy should outline the use of tools; such as Strata
for information collection and sharing of progress based
on specified criteria & a decision matrix for assessment
and prioritization

 Increased transparency of decision processes

can be achieved through education regarding
policy for management and staff as well as
Organization wide reported annual significant
purchase decisions.
 Weights
Priority
Criteria 0 Points 1 Point 3 points 5 Points Rating Points
Total = 100
Score

No improvement in patient health gain compared Minimal improvement in patient health gain Moderate improvement in patient health Vast improvement in patient health gain
Efficacy with current practices compared with current practices gain compared with current practices compared with current practices
Short/long term Health Gain
Population

Benefits cases with few alternatives

The technology address a condition with very low The technology address a condition with low The technology address a condition with The technology address a condition with
Health

Population Health prevalence (rate/100,000 < 1) prevalence (rate/100,000 btw 1-10) moderate prevalence (rate/100,000 btw 10 - high prevalence (rate/100,000 btw 1,000-
Prevalence/Incidence 1000) 10,000)
5-year projected prevalence

The technology does not represent the Standard of The technology represents standard of care The technology represents standard of care The technology represents new standard
Standard of care Care in other health regions in NL in some health regions in NL in most health regions in NL of care in our health region or NL
In other Health Regions
New Standard of Care

Not innovative Small gains in innovation Moderate gains in innovation Large gains in innovation
Knowledge & Research
Controversial documentation of safety Minimal documentation of safety Moderate documentation of safety High degree of documentation of safety
Safety
Has significant levels of controversy and ethical Has moderate ethical impact Has minimal ethical impact Has no ethical impact
Ethical Impact impact

The client does not accept this technology for use. The client has a moderate level of concern The client has minimal concerns with this The client is satisfied fully with the
Client Experience
Quality & Safety

with this technology technology performance of this technology

Patient comfort, ease of use, acceptability

Has significant negative social impact on clients Has moderate negative social impact on Has moderate positive social impact on Has significant positive social impact on
Social Impact & population clients and population clients and population clients and population

Significant training required in terms of cost, time, Moderate training required in terms of cost, Minimal training required in terms of cost, No training required
Training and number of individuals time and number of individuals time and number of individuals

Adds significant amount of additional workload Adds moderate amount of additional Adds small amount of additional workload Decreases workload and creates
End user impact workload workload efficiency
Efficiency, workload, routines, skill
Efficiency

No reduction in load on other services Minimal reduction in load on other services Moderate reduction in load on other services Vast reduction in load on other services
Service Coordination
Reduces load on other services

Does not support department strategic goals Minimal fit with department strategic goals Moderate fit with department strategic goals Strong fit with department strategic goals
Strategic Fit
High level of additional human resources required Moderate additional human resources Minimal additional human resources No additional human resources required
Sustainability Has no impact on the Healthy Workplace Program required required. Has Moderate impact on the Increases employee engagement,
Availability of human resources required (physicians, Has minimal impact on the Healthy Healthy workplace Program knowledge transfer and decreases sick
nurses, and support staff) Workplace Program leave.

Not sustainable or adverse impact on health Technology requires significant resource Technology requires start-up funds, but will Technology is viable and sustainable
Cost (Resources & Infrastructure) system funding over time (next 5 years). investment in order to be viable and be viable and sustainable following initial within available resources and/or
Sustainability

sustainable. investment. technology creates new resource capacity

in the local system.
No evidence of cost-effectiveness and/or cost- Minimal evidence of cost-effectiveness Moderate evidence of cost-effectiveness Clear evidence of cost-effectiveness
Economic Analysis (Cost benefit and/or cost-benefit and/or cost-benefit and/or cost-benefit
effectiveness & Cost benefit)
Risks associated with the technology cannot be Risks associated with the technology require Risks associated with the technology require Risks associated with the technology
Risk mitigated. a high level of mitigation. moderate mitigation. require minimal mitigation

No improvement in access Minimal improvement in access Moderate improvement in access High degree of improvement in access
Access Creates additional access to services Creates additional access &/or decreases Creates additional access, decreases wait
Access

wait times times, & moves services closer to the

client
The right service, the right time in the right place

OVERALL SCORE
/100
 When the HB-HTA process is:
◦transparent and trusted,
◦and those applying it are
knowledgeable and engaged
within a culture of HTA,

->the application of the

assessment process will be
consistent.
 Introduction

 Literature Review

 Research Design & Methodology

 Results

 Discussion

 Conclusion
Tonya Somerton B.N R.N M.T.M
Division Manager- Surgical Services and Children’s
Women’s Health Programs

(709) 945-5166

Carbonear General Hospital

86 High Road South
Carbonear, NL
A1Y 1A4
tonya.somerton@easternhealth.ca
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