The University of California, San Francisco (San Francisco, CA) was selected as a finalist for ECRI Institute's 5th Health Devices Achievement Award for developing an effective process to objectively evaluate the safety, efficacy, clinical appropriateness, and financial impact of new technologies for introduction into clinical practice.

The Health Devices Achievement Award recognizes outstanding initiatives undertaken by member healthcare institutions to improve patient safety, reduce costs, or otherwise facilitate better strategic management of health technology. ECRI Institute announced the winner and four other finalists for the 5th award in October 2010. Learn about the other submissions that achieved recognition. 

The Concept

The University of California, San Francisco (UCSF) has developed a very effective process to objectively evaluate the safety, efficacy, clinical appropriateness, and financial impact of new technologies for introduction into clinical practice. The UCSF Health Technology Assessment Program (HTAP), as it is called, is a physician-led process: All the voting members of the HTAP committee are physicians, with one representative from each service line. Nonclinical staff, such as the chief financial officer and a representative from purchasing and materials management, also participate on the committee by providing valuable input and offering varying perspectives, but they do not vote. The voting role of the physicians has been essential to establishing the credibility of the committee among clinical staff throughout the institution.

At UCSF, all requests for new products are first considered by the purchasing department. Any requests that are deemed to have substantial clinical efficacy, safety, or cost implications are then referred to the HTAP committee. The physician requesting the new technology creates a proposal to which HTAP's administrative director appends information about the technology's structure and function, U.S. Food and Drug Administration (FDA) approval or marketing clearance status, financial impact (including reimbursement information), results from previous clinical evaluations, and published studies that address clinical efficacy, target population, and adverse effects. The entire packet is distributed to the members of the committee before their monthly meeting.

Two technologies are considered at each hour-long meeting. The requesting physician makes a brief presentation, which is followed by a question-and-answer session between the committee members and the presenter. The requesting physician is then excused, and the committee deliberates and ultimately votes via closed ballot. Members can vote for a technology to be approved, denied, provisionally approved, or tabled until more information is obtained. All approved technologies are monitored over a 12-month period, with the facility examining factors related to utilization, efficacy, cost, complications, and reimbursement.

Since the inception of HTAP in 2006, 41 proposals have been considered; the committee has approved 24 and provisionally approved an additional 13. There is an appeals process in place for contesting denied proposals, but it has never been used.

UCSF has identified three main benefits to this technology assessment process:

1. Physicians are more aware of the financial impact of new technologies. This has led to a self-vetting phenomenon, whereby a physician will recognize that a new technology with limited clinical benefits may not be worth the increased cost. The high approval rate for proposals that are presented to the committee (about 90%) is a reflection of physicians taking a more analytical approach to requesting new technologies—that is, proposals that are likely to be denied are never made in the first place. And because the decisions are being made by their clinical colleagues, physicians do not see this process through an antagonistic lens, as often occurs with similar initiatives that are not physician-led.
2. The relationship between physicians and the medical center's administration has improved. The open discussion of cost concerns has led requestors to understand and accept the committee's decision, as evidenced by the fact that the appeals process has never been used. Physicians see administration as partners in providing the highest-quality, most cost-effective care, rather than as adversaries who are more interested in saving money than caring for patients. In fact, this collaborative approach has encouraged some physicians to use the HTAP as a forum to discuss new technologies without making official proposals. UCSF sees this as evidence that HTAP has fostered a culture of receptive, multidisciplinary, team-based decision making.
3. The HTAP process helps ensure the delivery of high-quality, cost-effective patient care by requiring that all selection decisions be evidence-based. Before HTAP, an influential physician could bypass the process that had been in place and take requests for new technology directly to the chief executive officer or chief medical officer. But now all decisions are based on merit, rather than influence. In addition, by providing a formal, transparent, and objective review of clinical claims, HTAP protects frontline clinical staff from being persuaded by a vendor's overstated claims of efficacy and therefore helps UCSF minimize the adoption of inappropriate (and expensive) technologies that offer limited clinical benefit.

Best Practices for Other Facilities

The UCSF technology assessment program is another example of an initiative that addresses the kinds of problems that all hospitals face: Every hospital has to decide which technologies to invest in, and many struggle with the assessment part of the process. In UCSF's case, having physicians make up all of the voting members of the technology assessment committee rendered the process more legitimate in the eyes of the physicians requesting a new technology. At other facilities, technology assessment committees that function in a similar manner may allow nonphysician members to vote.