For EHR Reporting Program, cost transparency is top of mind

Electronic health record software costs hospitals and health systems millions and even billions, often eating into their bottoms lines. To give providers a better idea of how the software will affect them financially, vendors should be required to submit maintenance and upgrade cost information to the Office of the National Coordinator for Health Information Technology, according to groups commenting on the office's EHR Reporting Program.

Overall, organizations were supportive of the ONC's yet-to-be-developed EHR Reporting Program, intended to publicly disseminate information about certified health information technology products—including information about security, interoperability, and usability. The program will require developers to submit some information, and end users will voluntarily submit other information.

While comments varied, with letters touching on security, interoperability, training, and other topics, many organizations pointed specifically to cost transparency as a crucial requirement of the program.

Today, those costs often remain hidden. According to the ONC, citing numbers from the early 2000s, the estimated average upfront cost for an on-premise EHR is about $33,000 per provider, with an additional cost $4,000 per provider per year.

In reality, that spells installations that range into the millions and even billions of dollars, often hitting hospitals' operating income. For instance, earlier this month, Trinity Health reported a $107.8 million asset impairment charge for its fiscal 2018 that was related to the transition to a single Epic EHR for its hospitals and continuing-care facilities.

Upgrades can be costly too. Major upgrades range from 20% to 49% of the original contract price, depending on vendor, according to a 2013 article in the journal Healthcare Financial Management.

Information about costs would help provider organizations take into account more than just technical features when choosing EHR software, according to comments submitted to the ONC on the program. Cost information goes beyond installation alone. Additionally, EHR vendors should report costs of maintenance, upgrades, training, and other areas, wrote Dr. Wylecia Wiggs Harris in the American Health Information Management Association's comments submitted to the ONC.

"The potential impact of acquiring, upgrading, customizing, and implementing a product that fails to meet the needs of an end user can be costly and protracted," Harris wrote.

Costs run beyond initial implementation. Hospitals and health systems must also keep their software relatively up to date to meet EHR incentive program requirements.

"The repeated and expensive upgrades or tools for interfaces that are required but not disclosed in certification documentation should cease, or at least be made transparent to purchasers via the EHR reporting program," wrote Ashley Thompson, senior vice president of public policy and policy development for the American Hospital Association.

Just as cost can change throughout a product's lifecycle, so can usability. A product might change due to how a hospital customizes it, for example. Some hospitals tailor alerts in an EHR to reduce alarm fatigue. By creating customized alerts for drug interactions, for instance, Sentara Healthcare reduced the alert override rate from between 93%-94% to less than 88%. In doing so, they also changed the how the software works.

To that end, the ONC should require information about products not only as they're designed but also as they're put in place, according to the Pew Charitable Trusts.

The ONC should "ensure that the usability aspects of the program focus on the facets of EHR usability that can contribute to unintended patient harm," wrote Ben Moscovitch, health information technology project director for the Pew Charitable Trusts.

Usability also depends on user training. Citing research it has conducted, KLAS Research noted that EHR satisfaction is "directly related" to how effective initial training is. "EHRs are not simple enough to be operated efficiently without ample instruction," wrote Taylor Davis, vice president of innovation for KLAS. "It is imperative that organizations create ongoing education programs that keep clinicians up to date on EHR capabilities."

Vendors should be required to report costs for this kind of training, according to the Medical Group Management Association. "It is very difficult for users of the (ONC online listing of certified products) to review costs and compare vendors," wrote Anders Gilberg, senior vice president of government affairs for MGMA.

Besides training, another way to boost satisfaction is to allow clinicians to personalize EHR tools, according to KLAS. This should be reflected in an EHR usability metric quantifying the personalization tools in an EHR that help clinicians more efficiently input and retrieve data and navigate the software, Davis wrote.

Clinicians are not the only end users of EHRs—patients are too. To collect patient reviews of EHRs, the ONC could look at patient surveys that are already circulated, according to AHIMA.

It might use a similar approach when gathering some provider feedback. "Utilization of existing data will help ensure that clinicians are not taken away from spending critical time with patients to meet the reporting requirements of the EHR Reporting Program," Harris wrote.

The ONC should try to "minimize" required reporting of data that's not already collected, according to consultancy Premier. Data are already collected, for instance, through the Promoting Interoperability program and the Quality Payment Program, wrote Blair Childs, senior vice president of public affairs for Premier.

The ONC might also automate some data collection to avoid further burdening providers, according to the AHA. A hospital already spends, on average, $760,000 every year to meet regulatory health IT requirements and $411,000 every year for the Promoting Interoperability Program, Thompson wrote. "A requirement that would mandate providers to report technology interaction would distract from their focus on patient care."