Economic Evaluation of an Investment in Medical Websites and Medical Web-Based Services

4 Challenges of the Research

Moreover, the accurate assessment of the “costs” and the “benefits” as well as the transformation of the intangible ones into easily comparable monetary units can be proved a quite difficult and demanding task requiring very careful planning and thorough investigations.

Furthermore, the methods that are used in this research in order to evaluate medical websites from an economic point of view are arisen many controversies and debates among the researchers in the scientific community about the underlying assumptions they use and the issues they have to deal with in order to produce valid results. The Cost Benefit analysis has to deal with the discounting of costs and benefits, the valuing of human life, and to deal with which method to use to estimate the monetary value of the intangible data. On the other hand, ROI calculation can produce a useful and credible performance measure by comparing costs and benefits, but this calculation is incapable to take into consideration the time and risk factors that are crucial for an accurate evaluation and a useful economic analysis (Endogmus H. et al., 2004). In addition to the above, the lack of standardisation of ROI processes in healthcare leads continuously into large variations in the estimations (Fitzner K. et al., 2005). Finally, WTP has to deal with survey based related biases that can affect the result and can cause large variations in the outcome. The correct application of the WTP approach is vital for the data collection required to fulfil the aims of the current research. The WTP survey requires thorough planning and careful question design in order to avoid the biases related to the web-based services of Willingness to Pay approach as well as to produce valid results.

Chapter 2: Literature Review

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   1. Introduction

The next part of this review will delve into the evaluation methods that are used in healthcare, comprehensively analysing the application of these methods in the healthcare sector, so far comparing it to the successes of these evaluation methods in other financial sectors. The methods that will be analysed are the Cost-benefit analysis (CBA), the Return on Investment (ROI) and the Willingness to Pay (WTP) approach. Our analysis will focus on special aspects that should be taken into consideration in order for such methods to be applied in the healthcare sector, as their respective advantages and disadvantages will be comprehensively identified and reviewed.

Finally the concluding remarks of this literature review will support and enhance the significance of this research’s contribution as the aims of this research will be presented with respect to with the existing knowledge gaps regarding the economic evaluation of the medical websites.

5Economic Evaluation in Healthcare

Furthermore, Puliam and Phillips (2008), pinpoint that nowadays more and more entities and organizations realise, the importance of evaluation processes, such as CBA and Return on Investment to be integrated in their processes and routines. Evaluation is now:

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  An important part of the design and plan of a process
  
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  Entities and organizations are taking more proactive actions and forming risk mitigation plans, using evaluation methods
  
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  There is a trend towards the systemization of the evaluation processes
  
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  Technology helps evaluation processes
  
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  Entities realise that only through careful evaluation planning success can come
  
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  Entities that are not applying an evaluation process suffer often budget reduction or even budget eliminations.
  

Figure : The steps of an economic evaluation Stone P. (Stone, 2005)

In healthcare decision makers make decisions at three different levels, a macro level that affects policy processes and interventions, a meso level that affect administrative processes and interventions, and a micro level that affects clinical practices. Drummond et al. (1982) suggest that one of the main reasons for the inefficiencies in healthcare system in general and more specifically considering NHS, is the lack of evaluation. Although there are many studies and processes covering the clinical evaluation, economic evaluation is very scarce. Moreover, Hoffmann et al. (2002) recognize also the need for economic evaluation investigating if the economic evaluations are useful to healthcare decision makers. They suggest that the quality of current studies is variable and they resulted in the fact that although decision makers consider evaluation useful, only a few studies address the decision-makers’ questions and they emphasize the need for more studies concerning evaluations in the healthcare sector.

In addition, it was recognised since 1985 that evaluation primarily has a political dimension, mainly in enabling government to control the allocation of resources and in general the decision making in large organizations, such as healthcare, under the direct influence of political institutions (Carr-Hill, 1985). Moreover, the classic evaluation model of healthcare is based on the reality that patients, medical practitioners, staff and resources are distributed across the various departments and sections which are expected to fulfil the pre-set objectives of the healthcare system (Carr-Hill, 1985). For every healthcare system the objective is to provide quality healthcare services, safe to the public, in the most efficient way. Furthermore, the decision maker or the researcher who will conduct the evaluation analysis should first understand and then evaluate the relationship among the inputs (human resources, capital and other resources) and also between the inputs and the sections of the healthcare system (Carr-Hill R., 1985). Finally it is emphasized that one reason that many times evaluations do not produce useful results for the decision maker is because the contexts of the purpose of the evaluation, of clearly defining the subject to be evaluated, and of defining of the actor for whom the evaluation process results will be produced, are often neglected or they were not being well defined, something that still remains one of the most problematic issues concerning the correct implementation of an evaluation process (Carr-Hill, 1985).

Moreover, Brousselle and Lessard (2011) support the idea that, in recent years, organizations like the National Institute for Health and Clinical Excellence (NICE) in England and Wales and a growing number of health technology assessment (HTA) agencies, are now established around the world, resulted in the institutionalization of healthcare economic evaluation. They support the opinion that as more and more decision making processes are based on evidence rather than subjective factors, economic evaluation is expected to evolve and become more effective in supporting managers and policy makers.

The study of the extant literature on the evaluation processes in the healthcare field reveals factors that hinder the decision making processes. Drummond et al. (2005) rightly pinpoints the fact that the complexity of economic evaluation processes has the disadvantage that it leaves important margins to the decision maker’s discretion. These authors state also that it is difficult for the decision makers to generalize the finding from an economic evaluation process. In addition to Drummond et al., Puliam and Phillips (2008), state that evaluation planning is important in every evaluation process in order to minimise the impact of the aforementioned factors that can hinder the decision making process. In their work, they identified four components needed for a successful evaluation:

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  The evaluation purpose must be clear, focusing on the purpose of the evaluation and defined before the development of an evaluation plan
  
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  The difficulties of the identifications of the impacts and consequences of the evaluation implementation as well as the feasibility of the application of the particular evaluation method must be examined.
  
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  The evaluation activity objectives must also be defined in order to drive the evaluation process in the right direction.
  
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  Researchers and analysts must take into consideration the various sources for the data they need in order to conduct an evaluation process and the timing of data collection.
  
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  An issue that is overlooked in most evaluation processes is to find ways to isolate the characteristics and interactions of the target under evaluation that can hinder the process and lead to invalid and misleading results.
  

Moreover, according to Donaldson et al. (2002), the basis of economic evaluation is the fact that the use of resources to meet a need incurs an opportunity cost -that being the benefit- which could be obtained by the next best use of those resources. When benefits are maximized and opportunity costs minimized then there is efficiency. Cost-Benefit analysis is an evaluation method that uses estimates of costs and benefits to provide a performance measure useful for almost every decision making process. Finally, Johannesson (1996) stated that in the healthcare field economic evaluations were based initially n on the human-capital approach according to which the value of the improvements in healthcare interventions is defined as “the difference between the decrease in consumption in healthcare and the increase production”. Soon after a strong criticism from the scientific community, the human-capital approach was replaced by Cost-Benefit and Cost- Effectiveness and Cost-Utility analysis that are based more on the Willingness to Pay concept.

5.1Evaluation and Accountability

In the literature covering ethics and governance terms, “accountability” is synonym to the expectation of account-giving processes, actions and documentation. Accountability is a very important term encountered very often in relation to governance issues in the public non-for-profit sector and thus is significant for the healthcare evaluation processes (Williams, 2006). In a decision making context, accountability can be defined as the acknowledgment and assumption of responsibility for various policies development (Williams, 2006).

According to Philips (2003) the continuously growing budgets and project expenses force entities and organizations towards accountability. He identified eight universal trends concerning the impact of evaluation on the accountability. These eight trends are presented below:

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  Evaluation is considered an internal process that should be part of the design development and functional life of a project under evaluation.
  
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  There is a trend for organizations to focus more on proactive actions as a result of a continuous evaluation processes Evaluation methods are based on a methodology and a framework that guides in a systematic way the evaluation process step by
  
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  Evaluation processes are utilising current technology to enhance their accuracy and effectiveness
  
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  Evaluation design, planning needs assessment, are considered now as the most important step and a crucial factor for the evaluation efficiency.
  
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  Organizations that do not adopt or rely on systematic evaluation procedures tend to suffer from budget reductions.
  
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  The web-based services of the evaluation processes are becoming more and more successful and efficient
  
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  Evaluation methods do not require the consumption resources and add only a small amount of extra costs to the program implementation.
  

2.2.2 Complexivity and Reflexivity in Healthcare Evaluation

Newton’s “clockwork universe” concept compares the universe to a mechanical clock. It continuously “ticking” or operates, as a perfect machine, with its gears governed by the laws of physics, making every “move” or aspect of the machine predictable (Plsek and Greenhalgh, 2001)

In 2001, Plsek and Greenhalgh presented the view that Newton’s “clockwork universe” had a strong influence on healthcare sciences, promoting the idea of breaking it down into simpler components, socio-medical problems in order to improve analysis and deep understanding of the various issues that decision /policy makers in this sector have to face. But decision making concerning healthcare units can be considered as a more complex process that affects society and it is affected by political and socioeconomic factors (Clark, Potter, Mckinlay, 1991).
“Complex adaptive systems are characterized by a large number of dynamically interacting and interconnected elements and information exchanging through relatively rich means” (Anderson et al, 2005).

Complexity theory as a framework can drive economic evaluation towards a deeper understanding and explanation of the aspects under evaluation. According to Anderson and MacDaniel (2000) Anderson et al (2005), and Gatrell (2005), complexity theory can provide added value and estimated towards a more comprehensive frameworks than existing frameworks concerning economic evaluation.

Reflexivity has a lot of influence in economic evaluation. Bourdieu and Wackquant (1992) state that “reflexivity entails the systematic exploration of the “unthought” categories of thought which delimit the thinkable and predetermine the thought. According to them reflexivity is an attempt to objectify rather than to subjectify. According to, Guillemin & Gillam 2004 the use of reflexivity in economic evaluation can improve the quality, and validity and help to identify crucial factors, constraints and limitations. Lassard (2007) states that “reflexivity matters how the problems are defined and analysed and thus what types of results can be obtained”. Also he states that although economic evaluation processes can be considered quantitative, the uncertainty that exists in the identification of cost, and effects in the monetization of intangible effects and in identifying constraints and limitations, is not. Guillemin and Gillam (2004) suggest that reflexivity can add a more ethical perspective to evaluation processes stating that “being reflexive in an ethical sense means acknowledging and being sensitized to the ethical dimensions of research practice”.

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