IMPROVING HOSPITAL BASED TECHNOLOGY ASSESSMENT: A SYSTEMATIC AND

IMPROVING HOSPITAL BASED TECHNOLOGY ASSESSMENT: A SYSTEMATIC AND

IMPROVING HOSPITAL BASED TECHNOLOGY ASSESSMENT: A SYSTEMATIC AND COLLABORATIVE APPROACH TO ASSESSING HEALTHCARE TECHNOLOGIES FOR EFFECTIVE CLINICAL DECISION-SUPPORT. Tonya Somerton BN RN MTM April 12, 2016 Disclosure: I have the following relevant financial relationships to disclose: Employed by: Eastern Health- Regional Health Authority, NL Division Manager Overview

Introduction & definitions Why did I research this topic? What was the goal of my thesis research? What did I discover in my literature review & research conducted at Eastern Health? How can that information help other Health Authorities?

Introduction & definitions Healthcare Technology Assessment (HTA) is the systematic evaluation of the properties, effects, and/or impacts of health technology. Purpose- to address the direct, indirect, intended, and unintended benefits and consequences of the adoption of healthcare technology . -Hailey, Babidge, Cameron, & Davignon 2010 HTA is conducted at several levels: Internationally Health Technology Assessment international (HTAi) ,

International Network of Agencies for Health Technology Assessment (INAHTA). Nationally European network for Health Technology Assessment (EUnetHTA) National Institute for Health and Clinical Excellence (NICE), Agency for Healthcare Research and Quality (AHRQ) in the United States Canadian Agency for Drugs and Technologies in Health (CADTH) in Canada. Provincially Institute of Health Economics (IHE) in Alberta Linstitut National dExcellence en Sante et en Service Sociaux (INESSS) in Quebec Ontario Health Technology Advisory Committee (OHTAC Newfoundland and Labrador Centre for Applied Health Research (NLCAHR -Canadian Agency for Drugs and Technologies in Health [CADTH], 2012 Regionally Various Regional Health Authorities (RHAs) within a Province Locally Various sites or Programs within a RHA.

Research Focus: Hospital Based (HB)-HTA or/ Local HTA Why did I research HB-HTA & technology decision making in Healthcare? About my experiences About Eastern Health Eastern Health HB-HTA To be useful to decision makers, HTA must

be tailored to the decision nodes of the healthcare system and the needs and interests of decision makers at each of these nodes -Organization for Economic Co-operation and Development, 2005, p. 92 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 factorOpportunities and advantages vary based upon the resources and competencies available within a healthcare organizations divisions. 3. The need to push forward scientific evidence to clinical practice. -HTAi, 2007

Why prioritize healthcare technology spending? New Healthcare technologies are introduced daily n o i ct y u d log o r o t In chn te

of w e n lth a he r ca e Funding for healthcare is decreasing

M te on c h ey no a lo v a gi ila es b le to bu y ne w

Healthcare organizations must be fiscally responsible, balancing funds & quality healthcare H $ Our Responsibility? Assessment & Prioritization of healthcare technologies. Without a systematic approach to assessment, it is possible that medical technologies may be introduced into clinical practice that cannot be utilized to their full functional capability or they may not be compatible with other existing technologies, work processes, resources or practice approaches . If we are going to prioritize, were going to need

some priorities What was the goal of my thesis research? My hope is that the recommendations from this research can assist Eastern Health and other 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 Systematic Standardized Consistently Applied

GOAL: Decision Support Methodology Combined an: exhaustive literature review, a brief but real case study of a failed technology assessment, a survey of key decision makers, focus groups with managers and staff at Eastern Health, and a series of interviews. What did I discover in the literature? HB-HTA Models

HB-HTA Models Percentage of Worldwide Organizations using the recognized HB-HTA Models 23 3 63 10 Internal Committee Mini HTA Ambassador HTA Unit -HTAi, 2007 Elements of HTA in the Literature

A written HTA Organizational Policy Clearly defined and widely circulated scope of assessment Unbiased and transparent processes A multi-criteria approach via standardized tools Exploration of all available data through multiple tools Inclusivity of all health technologies to avoid distorted decision making Stakeholder involvement

Multiple pathways for technology review Clear prioritization systems Acknowledgement of limitations 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 Well developed HTA processes possess the following characteristics: 1. They influence decision making and are trusted as methods to aid decision making. 2. They influence the adoption and diffusion of technology.

3. They influence health outcomes/efficiency and equity by sharing the methods and the results to be used at the local level. -Haas et al. (2008) Decision-making Criteria in Healthcare Main aspects for decision criteria identified in the literature Poulin et al., 2013 Draborg et al, 2005 JohnsonMasotti & Eda, 2005

Goetghebeu r et al., 2008 Health Gain Service Delivery Strategic Fit Innovation Financial Clinical Economic Patientrelated Organizationa l Patient centered

Organizational External Quality of evidence Disease impact Interventio n Economics Decision Making The rational decision-making model includes six steps and describes how individuals should work through decisions to maximize the outcome.

A mathematical model that support multicriteria decision making: Decision Matrix Model. 1. Define the problem 6. Select the best alternative 2. Identify the criteria 5. Evaluate the alternatives 3. Allocate

weights to the criteria 4. Develop alternatives -Langton, Robbins, and Judge (2011) Decision Matrix A decision matrix is a process to assist in choosing the best alternative. It applies numerical weights to the criteria being used to choose a product or technology. When the criteria are scored for each alternative, preference is given to the alternative with the best score. In the matrix, the rows represent the criteria and the columns represent the alternatives. An additional column represents the scored weights

The decision matrix method is simple, efficient, and can be quite effective. -Fraser et al, 2009 What did I discover at Eastern Health? Strategic Priorities Quality and Safety Access Sustainability

Population Health -Eastern Health, 2014 Decision Criteria Research findings: Approach to local level HTA and decision making processes are not consistently applied throughout the organization. Pathways for technology assessment and decision making are not clearly defined.

There is no policy to guide HB-HTA nor technology acquisition decision making leaving processes open to interpretation. Stakeholders: middle managers, frontline staff, patients are not involved to the level they could or should be. Data collection in relation to specific decision criteria is not standardized & the tools to collect this information is not priority focused or user friendly.

Assessment is not comprehensive due to inconsistently applied decision criteria. Criteria for decision making are not identified or communicated to requestors, leaving some important criteria unassessed unknowingly. The decision making process at all levels is vague and non-transparent. Timelines regarding approval and stage in the approval process is not clearly communicated

to the requestors. How can this information help EH & other Health Authorities? Framework development Based on: the literature review the research conducted at Eastern Health in relation to HTA practices, and decision making criteria and prioritization methods used by Eastern health decision makers Identifies areas to work on to improve HBHTA.

A Framework for improving HBHTA Model/ Process/ Transparency An organization the size of EH requires dedicated resources to oversee HB-HTA. Most HealthCare Agencies use the HTA Unit as it provides higher quality results. All Canadian RHAs should establish a HTA Unit. Local HTA Advisory Committee Canadian RHAs should establish local HTA advisory committees as an adjunct to the HTA Unit. These committees would make

recommendations to executive Knowledge Pathways for HB-HTA Establish clear pathways for technology assessment. Policy Development Clarify: expectations, scope, roles and responsibilities, means of information collection, standardized tools, and pathways for evaluation. Increase Stakeholder involvement Build into Policy- Patients, Frontline, Managers, Directors,

Support Programs Analytical Decision Making Seek all available data Improve Information collection tools (Forms/Strata) Increase assessment comprehensiveness Continue/validate criteria, establish weights for criteria Decision Support Tools Increase decision-support tools for

managers and directors using a Priority Setting System: Build expectations into Policy Screening/Request Forms Multi-criteria decision matrix Screening for pathway Managers presenting requests for technology need guidance on which pathway would be best based on specific criteria. Example : Alberta Health Surgical Services Standardized information gathering and case presentation

Giving managers an all inclusive form to complete regarding the technology request will guide information to enable decision making committees to use the same criteria. Example: Alberta Health Services- SSCN -Alberta Health Services (AHS) Surgery Strategic Clinical Network (SSCN) Decision Tools Consistent application of decision tools standardizes decision making practices. A Decision Matrix tool integrates the organizations

strategic priorities as well as the decision criteria that managers as a collective at Eastern Health are already using. -Any organization can contextualize such a tool The tool uses a weighted decision matrix for a mathematical multi-criteria analysis of technologies for prioritization. The steps required to use the Matrix Decision Support Tool are: Step 1- Assign a weight to each criteria based on importance to the decision. Together all assigned weights will total 100. Step 2- Assess each technology using the points system of 0-5, based on data collection tool (i.e. Strata or via Technology Request Form.) provided by the requestor of the

technology. Step 3- Multiply each criterions rating points with its weight and write it in the far right column (Score). Step 4- Total all criterion scores in the far right column. Step 5- Prioritize based on the overall score of individual technologies at the bottom. Population Health Priority Criteria 0 Points 1 Point 3 points 5 Points

Efficacy No improvement in patient health gain compared with current practices Minimal improvement in patient health gain compared with current practices Moderate improvement in patient health gain compared with current practices Vast improvement in patient health gain compared with current practices The technology address a condition with very low prevalence (rate/100,000 < 1) The technology address a condition with low prevalence (rate/100,000 btw 1-10)

The technology address a condition with moderate prevalence (rate/100,000 btw 10 1000) The technology address a condition with high prevalence (rate/100,000 btw 1,000-10,000) Short/long term Health Gain Benefits cases with few alternatives Population Health Prevalence/Incidence 5-year projected prevalence Standard of care In other Health Regions New Standard of Care Knowledge & Research

Safety Ethical Impact Client Experience Patient comfort, ease of use, acceptability Social Impact Training Quality & Safety Efficiency The technology represents standard of care in most health regions in NL The technology represents new standard of care in our health region or NL Not innovative Small gains in innovation

Moderate gains in innovation Large gains in innovation Controversial documentation of safety Minimal documentation of safety Moderate documentation of safety High degree of documentation of safety Has significant levels of controversy and ethical impact The client does not accept this technology for use. Has moderate ethical impact

Has minimal ethical impact Has no ethical impact The client has a moderate level of concern with this technology The client has minimal concerns with this technology The client is satisfied fully with the performance of this technology Has significant negative social impact on clients & population Significant training required in terms of cost, time, and number of individuals Has moderate negative social impact on clients and population

Moderate training required in terms of cost, time and number of individuals Has moderate positive social impact on clients and population Minimal training required in terms of cost, time and number of individuals Has significant positive social impact on clients and population No training required ach ) e ate oints R . 2 (p a

i r e crit Adds small amount of additional workload Decreases workload and creates workload 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 Does not support department strategic goals

Minimal fit with department strategic goals Moderate additional human resources required Has minimal impact on the Healthy Workplace Program Technology requires significant resource investment in order to be viable and sustainable. Moderate fit with department strategic goals Minimal additional human resources required. Has Moderate impact on the Healthy workplace Program Cost (Resources & Infrastructure) High level of additional human resources required

Has no impact on the Healthy Workplace Program Not sustainable or adverse impact on health system funding over time (next 5 years). Economic Analysis (Cost No evidence of cost-effectiveness and/or costbenefit Minimal evidence of cost-effectiveness and/ or cost-benefit Moderate evidence of cost-effectiveness and/or cost-benefit Strong fit with department strategic goals No additional human resources required Increases employee engagement, knowledge transfer and decreases sick

leave. Technology is viable and sustainable within available resources and/or technology creates new resource capacity in the local system. Clear evidence of cost-effectiveness and/ or cost-benefit Risks associated with the technology cannot be mitigated. No improvement in access Risks associated with the technology require a high level of mitigation. Minimal improvement in access Risks associated with the technology require moderate mitigation. Moderate improvement in access

Risks associated with the technology require minimal mitigation High degree of improvement in access Service Coordination Reduces load on other services Availability of human resources required (physicians, nurses, and support staff) effectiveness & Cost benefit) Risk Total = 100 ply ht i t l

u M eig . W 3 by g n i Rat Adds moderate amount of additional workload Efficiency, workload, routines, skill Strategic Fit Sustainability Sustainability

The technology represents standard of care in some health regions in NL Adds significant amount of additional workload End user impact Weights ign each s s 1. A ht to g wei ria e crit The technology does not represent the Standard

of Care in other health regions in NL 5. Compare alternatives by overall score Rating Points Technology requires start-up funds, but will be viable and sustainable following initial investment. 4. To tal s core Score Prioritization

Using the contextualized multi-criteria decision matrix tool, needs for healthcare technologies can be assessed and then prioritized. Outcomes Improve Timeliness Increase efficiency, Share expected process timelines Review outcomes: Reassess before automatically replacing technology for changing needs Assess whether implementations were

successful Listen to the frontline when assessing Track issues & learn from mistakes 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. Conclusion Multi-criteria decision making is complex. However, it is the nature of daily decision making in healthcare. Systematic analytical collaborative approaches are necessary to organize criteria, assess context, and analyze the alternatives.

Clearly articulated decision criteria and their importance to the organization are essential to informed decision making. Questions? Thank-you! Tonya Somerton B.N, R.N, M.T.M Division Manager- Surgical Services and Childrens Womens Health Programs (709) 945-5166 Eastern Health-Regional Health Authority Carbonear General Hospital 86 High Road South Carbonear, NL A1Y 1A4 [email protected] ca.linkedin.com/in/TonyaSomerton https://www.twitter.com/AAC_Director

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