Innovations in patient care and technology are constantly emerging to improve health care. Each new advancement claims to be better than what is currently available. But, with so many new devices and procedures entering the market, it can be difficult to determine which ones should be adopted and which ones should be rejected. There are numerous factors to consider, including clinical evidence, device costs, current practice and alternatives, reimbursement rates, patient selection and implementation issues.
“Evaluating an innovative technology is fundamentally different than evaluating commodities. It is difficult, because there is more risk and more reward,” said Joe Cummings, PhD, senior associate, technology assessment, performance improvement collaboratives at Vizient. “Ultimately, assessing health care technology is about buying outcomes, not devices. The key to success is creating a systematic, open and objective process focused on the clinical evidence, financial value and timing.”
Fortunately, clinicians and supply chain leaders can use a few basic strategies to assess, and potentially make a case for, the adoption of innovation. “Applying some practical tools and analyses allows decision-makers to see where an emerging medical technology falls on the spectrum and guides the technology adoption strategy,” Cummings said.
Plotting a course for adopting innovations
To start the technology assessment process, Cummings uses a nomogram (Figure A) to plot three key evaluation elements: anticipated clinical benefit, technology risk and financial impact. These are then used to determine the appropriate level of clinical evidence that should be available to support adoption.
For example, in Figure A, if there is a large anticipated clinical benefit, a small technology risk and a favorable financial analysis, then evaluating an innovative technology may require less evidence, like a small case study, to support adoption. These technologies typically hit the innovation sweet spot, combining clinical need, technical capability and favorable economics.
“Identification of these technologies can speed up the adoption process and get innovative technologies into widespread use more rapidly. This is a win for patients and hospitals,” said Cummings.
Anticipated clinical benefit is rated by how well the innovation can improve key patient outcomes, such as prolongation of life, reduction in pain or improvement in function. For example, a neuromodulation technology such as a peripheral nerve stimulator can be an effective pain management device that eliminates the need for opioid medication. Given the current opioid epidemic, the latter suggests a large anticipated clinical benefit.
Innovative technologies often have large anticipated clinical benefit when they target an area where no good treatment alternatives exist. If there are already a lot of good alternatives, the potential benefit is incremental and the technology may not be all that innovative.
Innovative technology with a large risk could include an implanted device, whereas a diagnostic technology used outside the patient’s body might rate as a small risk. Because of the impact on patient safety, high-risk technologies usually require a higher burden of proof, like randomized clinical trials, for the appropriate level of evidence.
The financial impact column factors in purchase costs and total treatment costs relative to reimbursement. If the financial impact to the hospital is favorable to neutral, a lower evidentiary burden of proof may be acceptable. Unfortunately, most innovative technologies are priced at a premium, which often presents a significant barrier to hospital adoption.
Charting technology value
Determining the value of a technology is another key to the innovation adoption process. This is especially true in the era of alternative payment paradigms like value-based care. Technology value can be plotted as the relationship between outcomes and costs (Figure B).
In this figure, the dot in the center represents the current treatment. From that point, a new technology can either improve or worsen outcomes and increase or reduce costs.
An innovative technology can fall anywhere to the right of the decision threshold line, but the innovation sweet spot is in the lower right quadrant.
Most innovative technologies fall in the upper right quadrant with a better outcome, but also a higher cost. Mobile stroke units are an emerging, potentially innovative technology that falls in this quadrant. Interestingly, the lower left quadrant is where many disruptive technologies originate.
“To use a value-based evaluation paradigm, the hospital’s technology adoption committee must engage in a systematic review of the clinical literature to determine pertinent outcomes and also conduct financial analysis to estimate the total cost of care,” Cummings said.
Determining the optimal time for adopting an innovation
When should a hospital implement an innovative technology? Most would deem that the early adopters of a technology are the innovators. If it turns out that the technology eventually becomes the standard of care, then these truly were the innovators. However, many potentially innovative technologies never get widespread adoption for various reasons and therefore the early adopters chose wrongly. This is why the right timing is closely linked with the evidence development process (Figure C).
“I often recommend hospitals try to be in the early majority phase when considering technology adoption,” Cummings said. “Innovators (early adopters) only know that it can work, but they don’t have proof just yet that it does work as advertised, and that’s where the risk comes in. In the early majority phase, you still get most of the benefit of early adoption, but mitigate the risk somewhat. It's OK to be an early adopter to fulfill a research mission, but you should make the technology adoption decision knowing that the evidence is not yet mature.”
A hospital can also mitigate some of the adoption risk by piloting a technology in a limited usage at their institution. Collecting some data on outcomes, costs and reimbursement may be used to more fully inform the ultimate decision whether to adopt the technology.
Putting it all together
The above tools are an integral part of the Vizient Technology Assessment Program process and are key components of the TechFlash reports produced by Cummings. These reports include a comprehensive analysis to help Vizient members better understand new and emerging technology and guide their adoption plans. Each TechFlash details the technology’s adoption status, outcomes and costs, and uses the tools discussed above to analyze the technology.
“Recently, I evaluated a minimally invasive treatment for benign prosthetic hyperplasia,” Cummings said. “Based on a moderate expected clinical benefit, low technology risk and neutral financial impact, I determined a need for at least moderate quality evidence, which does exist in the clinical literature. Since it is typically reimbursed and demonstrates positive comparative outcomes, my ultimate recommendation was this is an adoptable innovative technology.”
Cummings regularly shares TechFlash findings in interactive webinars where members can ask direct questions and get his feedback. “TechFlash reports are intended as a tool to use in the evaluation process,” Cummings said. “It provides substantial information and does the research legwork that hospitals would otherwise have to create themselves before making their ultimate decision.”
Members currently participating in a Vizient Performance Improvement Collaborative will see new TechFlash reports in the Performance Management Digest. For members not participating in a collaborative who would like more information, please contact Joe Cummings.