Healthcare providers have always sought to provide the best patient care possible given their financial constraints. Judiciously bringing in new medical technologies is a crucial part of that mission. A well-thought-out technology assessment process – one that involves physician input and evidence-based medicine – can help.
When Boston Scientific suspended sales of its acid reflux disease treatment Enteryx in September 2005, George Hersch took note. Hersch is vice president of materiel management of Norton Healthcare, Louisville, Ky. A little more than a year earlier, Norton Healthcare’s Technology Assessment Committee had decided against bringing it into the IDN.
“I sent the alert to members of the committee and said, ‘This is why we have a structure like this in place – to ensure that we’re acting in the interests of best patient care and that we’re only providing technologies that are safe and efficacious,'” says Hersch. “This told me, ‘This is what works.”
Top of its game
Norton Healthcare operates five hospitals and seven (soon to be eight) immediate-care centers in the Louisville, Ky., area. The IDN also owns 28 physician practices. With 48 percent of the Louisville market and the only freestanding children’s hospital in the state, the IDN is particularly strong in oncology services, cardiac care, women’s services, pediatric care and ortho/neuro/spine services. Indeed, Norton Healthcare is a market leader – and it wants to stay that way. Bringing in the best medical technology is one way to do that.
“Technology considerations are often driven by our need to ensure that we are at the top of our game in these areas,” says Hersch, who began his career in materials management in 1977 as assistant director of materiel management at Saint Anthony Medical Center in Columbus, Ohio.
Still, Norton Healthcare – like all IDNs – needs some checks in the process. “Because we have many centers of excellence, there is much competition for limited dollars,” says Hersch. But technology assessment isn’t primarily about money. “Service-line leaders and their physicians must build a compelling case for improvements in patient care outcomes before such requests are funded.”
Hersch recognized the need for a strong technology assessment program while serving as associate director of materiel management at UCLA Healthcare in Los Angeles. “In 1998, there was serious concern about the rate at which our supply budget was increasing, and I was asked to look into it.” As an academic medical center, UCLA was adopting new technologies faster than anywhere else Hersch had worked, and those new technologies were busting the medical center’s supply budget. “So I laid out my vision of how we might control new technology adoption, by putting together a physician peer review council to look at the scientific merits of technologies that were coming onboard.”
For Hersch, the term “technology assessment” refers to high-end devices that sometimes have an equipment component.
UCLA’s CEO – himself a physician – fully supported the effort, and helped identify and recruit physicians with the “knowledge and the passion” for technology assessment. Two co-chairs were selected to run the committee – an OB-GYN specialist who was also a professor of medicine, and a surgeon at Santa Monica Hospital, which was owned by UCLA.
Hersch obtained permission to hire a full-time clinician to assemble reports and write summary overviews of each technology considered. “He was a respiratory therapist with experience in value analysis,” says Hersch. “He could not only understand the technologies, but also speak to the doctors and interpret the information he had found.”
To lend credibility to the process, Hersch subscribed to third-party technology-evaluation services, such as Plymouth Meeting, Pa.-based ECRI. “The importance of using a third-party, evidence-based tool was that we had no dog in the fight,” says Hersch. In other words, ECRI could be accepted by all as an impartial, third-party source of information.
As part of the process, every new technology had to have a “champion” in the medical staff, that is, someone who would personally present the product to the committee. After that person made his or her presentation, they would leave the room, so that the others could engage in a frank discussion on the technology’s merits. “We’d ask, ‘Is this a good technology? Will it improve patient care? What are the reimbursement considerations?'” says Hersch. “It was tough, because the champions were passionate about the new technology. But often, we found a better way to approach the need.”
In fact, the committee ended up approving approximately 70 percent of the technologies presented to it. Physicians could appeal its decision to the CEO. “But [the CEO] said, ‘Why would I overturn a decision made by my colleagues?’ He never overturned any of the committee’s decisions.”
Living with options
After spending nearly four years at UCLA, Hersch came to Norton Healthcare in October 2000. The two IDNs differed in one significant respect: Unlike the academic-based physicians at UCLA, most of Norton’s physicians were community-based (although some specialists were affiliated with the University of Louisville School of Medicine). Although Norton is a dominant player in the Louisville market, the doctors do have options. “There was the threat that they might move their business to another hospital in the community,” says Hersch.
But in another sense, the two IDNs shared a lot in common. First, like UCLA, Norton lacked a well-defined technology assessment process. Hersch quickly saw that the Louisville IDN could benefit from one as much as UCLA. Second, as he had at UCLA, Hersch got enthusiastic administrative support for instituting such a process. “Without that support, this process cannot succeed,” he says.
So he set about creating a technology assessment committee. And he got a high-profile one. At Norton Healthcare, the committee is one of four committees reporting directly to the IDN’s medical executive committee, that in turn reports to the board quality committee. (The other three are the credentialing committee, the pharmaceutical-and-therapeutics committee, and the patient safety committee.)
As he had at UCLA, Hersch set about educating the medical staff about the process, “helping them understand why we were doing this.” He promised them an objective process, aided by third-party sources such as ECRI and the Advisory Board Co., Washington, D.C.
To coordinate and disseminate the research findings, he hired Claire Rupert as division director of value analysis. Rupert, an RN with extensive OR supply chain and value analysis experience, established credibility with the physicians. “She is a tremendous researcher, highly skilled, and extremely conversant on technology topics,” says Hersch.
Norton Healthcare’s technology assessment committee comprises 11 physicians, the IDN’s CFO, the division director of value analysis and revenue integrity, and Hersch. A cross-section of medical specialties are represented, including internal medicine, cardiology, bariatric surgery, orthopedic surgery, anesthesiology, pulmonary medicine and oncology. As at UCLA, the committee considers primarily high-end devices which may or may not have an equipment component. Examples include carotid stents, peripheral vascular access catheters, the Merci Retriever for cerebral artery clot removal and Therasphere brachytherapy for unresectable hepatocellular carcinoma. The committee’s review also included the da Vinci¨ surgical system by Intuitive Surgical, Sunnyvale, Calif., which it considered to be of potential value in the delivery of nerve-sparing surgery for radical prostatectomies.
The process works like this: The hospital president and the appropriate department head sign off on the physician’s request that the committee review a particular technology. Rupert conducts and summarizes the third-party research, including data derived from manufacturers’ clinical trials. Then the committee meets (once a month, for 1 1/2-hour dinner sessions).
As at UCLA, the requesting physician presents the technology to the committee. After the presentation, he or she leaves the room, allowing the committee to engage in a frank discussion. The committee physician whose background most closely matches that of the presenter leads this discussion. Finally, the committee approves, denies or offers conditional approval for the requested technology. Physicians are compensated for their services as advisors if they don’t already hold a contract with the health system.
Many of the technologies are approved. However, since its inception 1 1/2 years ago, the committee has put the brakes on several, including the treatment for acid reflux disease and artificial discs.
More proactive, more retrospective
Up to this point, the committee has only considered technologies brought to its attention by the medical staff. But Hersch is trying to change that. “We are now beginning to look prospectively at new technologies before these requests come to us,” he says. “A big issue is identifying what is in the FDA pipeline, and obtaining enough information about the new technology to make a decision.”
In the future, Norton’s committee will also conduct year-end retrospective reviews of the technologies it has adopted. “It’s important to look back at the clinical and financial impact of the committee’s decisions to understand their value to patients and the hospital.”
Hersch sums up the importance of technology assessment this way: “If we look at new technologies from an evidence-based medicine review process, we take the emotion out of buying new technologies.
“Physicians are scientists who want to try new technologies in the interest of improving patient care. Unfortunately, not all new technologies deliver on that promise. A well-developed technology assessment program can safeguard our patients and ensure that we are good stewards of our community’s resources.”