HTM - Inhouse or Third Party?

Health Technology Management.

The Merits: “In-house”, 3rd Party or “Sub-Contract”!

Key influencing factors to decide on the best approach:

From “acute care” primary hospital to poly clinic - understand the need first!

HTM is the modern approach to the management of medical equipment in the operating environment and focuses on attaining the best potential economy of ownership and equipment “uptime” levels throughout the lifecycle of health technology devices. Through the implementation of Planned, predictive and corrective maintenance methodologies in line with ISO standards in order to reduce equipment downtime to a minimum and ensure best possible outcome in the use of health technology devices.

Best practice is to align maintenance practice to the user environment rather than the reverse while keeping in mind the cost and downtime implications of device ownership by accommodating for all eventualities that may influence overall cost of ownership.

Approach to HTM for any health services entity stems for what is best suited to the facility itself, especially from a geographical location point of view.

For acute service facilities located in big cities, in close proximity to OEM's and suppliers, a combination of an In-house department that can maintain upwards of 60-70% of the equipment in house while OEM's and suppliers look after the remaining 30-40% of equipment a good (cost effective) balance can be maintained as long as the in-house department manages the administrative requirements not accommodated for by OEM's, suppliers and vendors.

The same cannot be said for acute facilities located in remote areas where suppliers and OEM's are either non existent (Developing and 3rd world countries) or located at great distances from the facility. Here it may be best to either contract a “3rd party” multi modality service provider or have an in-house EBME department with an increase to 90% in-house maintenance to reduce the risk of higher charges with regards to traveling logistics, delayed parts inventory subject to imports, long distance deliveries etc.. All of which contributes to inflated economy of ownership and reduced uptime of equipment.

Third world and developing countries may not have the necessary multi-modality skill-sets to allow for in-house departments to employ full HTM programs and this is where Multi-Modality Managed Service (3rd party) providers come into their own as they have developed systems in place and can easily mobilise full HTM programs with the required staffing and trained skill-sets on short notice ensuring facilities operate at optimum uptime and in line with standards requirements within a nominal mobilisation timeframe.

This also can be used in skill-set upliftment of local incumbents in the developing world through period contracts with established managed service providers where the requirement is for such candidates to be trained on HTM methodologies during the contract period while they learn from skilled multi-modality individuals on a daily basis as well as participating in health technology and OEM Specific training courses.

Multi Modality (In-House and 3rd Party)

Multi Modality HTM systems can mean either an "In-house" HTM department or a contracted “3rd party" managed services HTM provider who fulfil the role of an "In-House' HTM department.

Depending on the Health services facility's geographical location, operational structure and proximal accessibility to technical support of health technology devices and educated / trained skill-sets will all determine the best possible choice of either "in-house" or “3rd party” service provider or both.

For some smaller facilities it is neither feasible to have an in-house department nor is it cost effective to engage with multiple vendors / suppliers / OEM's to travel to site for equipment support, in which case a 3rd party "multi-modality" service provider remains the only viable choice through an annual or bi-annual site visit. By the service provider whereupon all health technology assets are subject to PM and CM intervention procedures all at the same time.

In a lot of developing countries, 3rd party service providers also remain the choice of OEM's to provide service support due to the HTM structure of their service offering in line with ISO standards which in turn ensures compliance to these standards on behalf of the OEM.

Since third party providers are normally not restricted to distribution rights limited to specific OEM's, they can maintain multiple OEM agreements even for the same device designations across multiple OEM's as the emphasis is on standards compliant technical support rather than equipment sales which provide for a direct distinction in terms of objectivity against suppliers / vendors who try to engage in technical support on "non-represented" OEM equipment.

As with in-house departments, the 3rd party service provider's focus is on the percentage of in-house completed maintenance procedures through the engagement with OEM's on accessibility to technical training, parts and service materials and documentation.

By increasing the in-house completed maintenance procedures and limiting external support to as best possible a ration as possible, it allows for more desirable economy of ownership attainment and an overall reduction in health technology cost of ownership.

Third party service providers are historically also a good vehicle for developing countries to train local technical staff and students on projects where the ultimate goal is to both uplift potential candidate skill-sets and a comprehensive understanding of holistic HTM procedures and methodology. In some cases a combined approach by 3rd party services providers and local educational institutions helps attain a higher level of competence for graduate and under graduate students alike through the exposure to OEM's, practical procedures and HTM methodology in a managed environment.


In-House Departments

In-House departments have to have a measure of multi-modality support credentials with BMET's trained across a wide variety of equipment from different OEM's. Such a department also needs an HTM educated / trained manager to ensure the department's compliance to ISO standards. Depending on the number of technicians on-site, at least 60-70% of equipment should be accounted for in terms of in-house maintenance to ensure cost effective economy of ownership across the whole installed base of health technology devices on site. For sites with geographical location challenges, the in-house attainable figure should be increased to upward of 80-90% to ensure the same cost effective outcome.

Managed Services

3rd party

As with in-house departments and where the conditions are more suitable to 3rd party service providers, the emphasis remains on economy of ownership on behalf of the equipment owner. Ratio's of in-house completed maintenance should accommodate for satisfactory levels of economy of ownership on the owner's complete Health technology installed base through systems compliant to ISO standards and staff trained on both HTM methodology and OEM specific requirements.

OEM Advanced Service Provider (ASP)

Managed Service providers are also good candidates to provide standards driven service and technical support to OEM's who supply equipment in locations where they may not have adequate standards compliant service centres and where vendors / suppliers lack in the OEM specified service support networks and technical skill-sets.


Minimum Technical Qualification

The best candidates for multi-modality technical support whether employed directly by the health services facility or a third party provider should be approached on a tier level basis as the intervention specifications required for health technology devices varies from low risk to high risk. The minimum requirement for low risk equipment can be attained by an incumbent with at least an HNC qualification where as a managerial BMET will be more suitable to manage all components of HTM on the back of an M degree or at least an undergraduate degree with a suitable amount of experience gained over a minimum period of 3-5 years.

HTM Training

Health Technology Management requires a level of expertise that can only be attained with a combination of a minimum of undergraduate training combined with experience across all modalities and functions of the management of health technology devices including the topographical factors that impact the use and ownership of medical equipment.

These factors include but are not limited to legislation and regulation, Health & Safety, Quality Assurance, manufacturing directives, adverse incident control, recall management, Environmental impact limitations and regulations, traceability, historical records, key performance, analytics etc..

Multi OEM / Vendor Training

Skill-sets for multi modality support are greatly increased through training and certification with various OEM's across multiple device designations and models. Designation training in particular allows a multi-modality technician to maintain equipment even in the event where familiarity with a specific make and model may be limited.


Standards Driven Systems Implementation

Control systems and maintenance recording applications for in-house departments and 3rd party HTM Service providers are compliance driven to ensure all aspects of HTM are accommodated for.

Best practice would be to implement an enterprise management solution that can control both enterprise asset management and computerised maintenance management.

With modern HTM compliance criteria it is also advisable that the system or application incorporate process and task control for compliance on manufacturer's tasks and safety procedures in line with “Safe Systems of Work” (SSOW) and intervention specification criteria.


Depending on the Logistical placement, environmental and operational aspects of the health services facility as well as proximal access to technical support, it is advisable to either opt for an in-house EBME department or a specialist HTM multi-modality third party service provider.

Either of which should be able to implement a comprehensive HTM systems platform and maintain full compliance to applicable standards and regulatory requirements.

Limited Modality

The term "limited" or "single" modality refers to equipment suppliers / vendors / OEM's where the technical support emphasis is focused on specific "represented" OEM's and their related models as well as revenue generation rather than HTM. Unfortunately this leaves the equipment owner to still manage all other aspects of the equipment lifecycle and HTM requirements in line with ISO standards.

Operational limitations also have a major impact insofar OEM restrictions are concerned with conflict of interest and a lack of objectivity forcing "non-Represented" OEM's declining access to support materials, documentation and training to vendors and suppliers who already represent other OEM's on their sales portfolio for reasons including IP and copyright infringements.

In Europe and the USA, most OEM's who has historically had a managed services offering to market has either seized their operations or sold it off to independent third party and managed service specialist providers for this exact reason.

It is therefor never a good idea to commission a supplier or vendor regardless of country (whether first world or developing / third world) for the provision of HTM managed services for health services facilities.

"OEM specific" support systems and distribution restrictions, lack of multi-modality HTM platforms and structures, Objectivity, Pay per visit (PPV) support models etc.. all contribute to limited HTM service delivery to health services facilities that acquire equipment from multiple sources.


OEM Specific

Technical Service support from suppliers and vendors and in some cases also OEM's who sell directly to end-users are mostly limited to the OEM's they represent and is best supported on a "Pay per Visit" methodology to ensure sustainable revenue for the seller, whether OEM, vendor or supplier.

Warranty, Extended Warranty and Service warranty contracts helps the owner to control maintenance cost of ownership to one degree or another but it is still limited from an HTM point of view because the Vendor / supplier cannot assist the owner with any HTM requirements outside the actual service / repair assignment and it is still up to the owner to ensure compliance on all other requirements.


The skill-sets of single (limited) modality provider technicians are normally limited to the OEM's they represent and can therefore not be considered multi modality as suppliers / vendors are not subject to HTM requirements as is the case with the equipment owner.

Since there is a lesser emphasis on HTM, it is therefore more cost effective for suppliers and vendors to employ lesser qualified technical staff as it is more important for them to have their staff OEM trained than HTM educated.

This relates to technical staff that will always have limited exposure to HTM which results in a lack of multi-modality capability, unless the technician goes on to other employers in order to grow his personal training portfolio across various OEM's, designations and models.

Such a technician who is trained on multiple OEM equipment designations will provide for a better multi-modality candidate but will still be limited on overall HTM requirements.


Profit Driven Systems Implementation

Unlike multi-modality in-house and specialist third party providers who implement HTM compliance driven systems, vendors, suppliers and OEM systems are more aligned for revenue generation as they do not have an obligation to HTM requirements other than Planned and corrective assignments for which a job-card and service certificate submitted to the owner post-completion is sufficient.

In some cases the owner are given access to electronic records for historical intervention traceability but it has no real benefit to the owner as it is simply not feasible to maintain multiple vendor / OEM platforms since from a standards driven systems point of view, the in-house requirement is to maintain all installed base records on a singular system.


Based on the above study, the conclusion is that OEM's, suppliers, distributors and vendors are subject to a number of restrictions and limitations which inhibits their ability to provide multi-modality Health Technology Management services to health service facilities.

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