Health Technology Assessment has emerged over the last three decades as one of the most influential and contested instruments in health system governance. Originally designed to support rational decision making regarding the adoption and diffusion of medical technologies, Health Technology Assessment now operates in a radically transformed environment characterized by digital health systems, real world evidence, living clinical guidelines, and increasingly complex regulatory landscapes. This article develops a comprehensive and theoretically grounded analysis of Health Technology Assessment as both a methodological framework and a political and institutional practice. Drawing strictly on the foundational and contemporary references provided, the paper examines how Health Technology Assessment has evolved from a primarily evidence synthesis enterprise into a dynamic governance tool embedded within health system structures, regulatory agencies, hospitals, and international networks.

The analysis begins by revisiting the conceptual foundations of Health Technology Assessment as articulated by the World Health Organization, European institutions, and academic scholars. These definitions reveal an inherent tension between methodological rigor and contextual relevance, a tension that has been identified as one of the defining challenges of modern Health Technology Assessment. This tension is explored in depth through the lens of policy theory, organizational behavior, and knowledge translation. The article then situates Health Technology Assessment within the broader digital transformation of health systems, focusing on electronic health records, regional eHealth infrastructures, and the emergence of real world data as a key input for evidence generation.

Building on this conceptual groundwork, the article advances a detailed methodological discussion of how Health Technology Assessment can integrate traditional clinical evidence, economic evaluation, and ethical analysis with newer forms of evidence such as real world data and living guideline processes. The implications of these methodological shifts for decision making, innovation, and equity are critically examined. Particular attention is paid to the role of European collaboration frameworks, especially the EUnetHTA Core Model, and to the ways in which regulatory agencies increasingly rely on real world evidence to complement randomized controlled trials.

The results section synthesizes insights from the literature to demonstrate how Health Technology Assessment is now functioning as a hybrid system that links evidence production, policy deliberation, and clinical practice. The discussion section explores the limitations and risks of this transformation, including challenges related to data quality, institutional capacity, and the potential politicization of evidence. The article concludes by arguing that the future of Health Technology Assessment depends on its ability to remain methodologically robust while becoming more adaptive, transparent, and embedded within digital health ecosystems. In doing so, Health Technology Assessment can continue to fulfill its core mission of informing decision makers and promoting the efficient and equitable use of health technologies.