Trustee talking points

  • As health care becomes more complex and shifts its emphasis from volume to value, decisions on buying technology also need to become more sophisticated.
  • When considering new clinical technology, hospitals need to pay attention to its interoperabillity — not only with other technology but also with clinical processes — and the actual amount it improves outcomes.
  • Hospital and health system trustees can follow a simple test to guide their technology purchases.
  • Technology decisions depend on strategy and context. Some hospitals may need new, costly technology in certain areas, while others can successfully continue to use older equipment. 

As health care continues its shift from volume to value and from individual providers to large health systems, the rationales underpinning technology decisions and investments, especially when it comes to clinical technology, should change as well. Such change may be subtle, but it can have profound long-term implications on whether technology enables or atrophies health care productivity.

As a board, what does this mean for how trustees should think about technology to ensure that organizations reap the most from their investments? In some ways, we still need to make decisions about new technology as we always have. We should evaluate and prioritize our options and choose what delivers the best clinical, operational and financial return. 

That sounds simple. Many technologies deliver clear-cut value: Pacemakers keep people alive, so we buy and use them. But today, it is not always so simple.

In the evolving health care system, more sophisticated technology decisions will need to be made because:

  1. Financial pressures have pushed us not only to seek better outcomes but to judge and decide more clearly how much better an outcome needs to be to be worth spending resources on.
  2. The need to improve health care productivity has driven a need to better understand how new technology fits into or alters clinical and operational workflow for better or worse.
  3. The push for better technology interoperability creates a need to understand not just how an individual technology performs but how it performs as part of an overall provider system of other technologies and across various facilities, with clinicians outside facility walls, and with patients where they live, work and recreate.

Given this new reality, we suggest trustees adopt a "Triple E Technology Test" as a way to get the most out of new clinical technology. By using this simple test to guide their thinking, trustees can remember what key questions to ask themselves and their colleagues when confronted with new technology decisions.

In our Triple E Test, the first E stands for effectiveness. That is, how effective is a technology at improving outcomes? The question here is not whether but rather exactly by how much it improves outcomes.

The second E stands for efficiency. That is, does a technology help us improve our efficiency as a health care system? For example, will it improve our workflow and our ability to treat the most patients with the least wasted effort?

The third E stands for energy. That is, does a technology energize our strategy, our staff and our patients? Does it fit our vision of who we are trying to be and what we are trying to accomplish?

With this simple test, we can tackle complex technology decisions.


In trying to judge emerging clinical technology, we are usually most interested in understanding how the technology will improve outcomes. In our quick test, though, we are asking how much the improvement in outcomes truly is rather than simply whether there is an improvement.

Is there a 5 percent improvement or a 50 percent improvement? This difference is critical because virtually every new technology is purported to have a positive effect. What we must judge is how valid that claim is and then how significant it is: Is the evidence standing behind the claim credible and robust? And second, is the magnitude of the effect sufficient to justify its cost?

This second question is much harder to answer and often relies on making complex trade-offs. For example, 3 tesla MRI has some advantages over 1.5 tesla MRI, but is the added benefit of a more powerful MRI machine worth the additional cost at our institution? Different people may legitimately have different views about the extent of the benefit. It is precisely this type of value judgment that trustees have to weigh in on as decisions like this become more common.


The second E in our test, efficiency, reminds us that we must understand how new technology will integrate with people, processes, other technologies, and various facilities and environments in which it must fit. Delivering care is complex, time-consuming, labor-intensive work. Technology can make it easier, but it can also make it more complicated — in which case, it often becomes the enemy of efficiency.

An individual technology that is best of breed may not be worth it if it cannot interface well with the technology and processes in other systems. For example, just about every health care provider has infusion pumps — often, hundreds of them. They are costly to buy, costly to run and costly to manage.

In today’s world of infusion technology, the decision on which pump to select is often less about the pump itself and more about its interoperability with drug libraries, alarm systems and electronic health records. If the pump technology selected does not interface well with a provider’s existing health care systems (be they people, processes or technology), the result will be an increase in system entropy, not efficiency.


Our last E represents more of a right-brain approach to gauging whether new technology fits our vision of the future. It reminds us to ask whether a technology will energize our vision, our staff and our patients.

We need to ask, does the technology bring to life our organization's strategy? In this, there are several principles to remember: Passion and energy matter. We need our caregivers to have the right technology to do their jobs. And patients want to know the place they are entrusting their life with has the right technology available. It is true that new technology is not always better than its older version. Technology, however, has become an incredible enabler of progress, not only in health care but in society.

We may have determined we must be especially good in some areas. If so, we must align our technology decisions and investments accordingly. If our goal is to deliver cutting-edge cancer care because we are committed to research as well as patient care, then we should adopt a different mindset than if we are going to deliver standard cancer care and refer difficult cases to specialty centers. The technology decisions in these two cases should not be the same.

In contrast to more-conventional return-on-investment models often used by health systems, the Triple E Test lets us make decisions based on vision and alignment. If we are trying to be at the forefront of radiation therapy and cancer research, then developing a proton beam accelerator may make sense, even if it costs $100 million.

One size doesn't fit all

Health care technology has become complicated and specialized and often dizzying to understand. Yet we know that without technology, health care would be crippled, so decide on new technology we must.

We cannot say no simply because something is costly, and we cannot say yes just because something is better. We can, however, use our simple Triple E Technology Test to thoughtfully weigh the technology decisions we face. We can thus ensure we stay focused on the most critical principles and factors that should drive all technology decisions, regardless of clinical specialty or complexity.

If trustees and administrators remember our Triple E Technology Test, our communities will have the right clinical technology at the right place at the right time to give us the best care at the best price. And that would be truly excellent.

Anthony J. Montagnolo, M.S. (, is executive vice president and chief operating officer of ECRI Institute in Plymouth Meeting, Pa.

Trustee takeaways 

The "Triple E Technology Test" provides an easy-to-use guide for a health system's technology purchases. Here's what its three elements mean:

Effectiveness: The degree to which something is successful at improving patient outcomes or producing another desired result.

Efficiency: The ability to do something or produce something without wasting materials, time or energy.

Energy: The ability to bring a strategy to life, or the physical or mental strength that allows a hospital to energize its vision, staff and patients; the natural enthusiasm and effort within an organization.