Fee frus­tra­tions

Con­nect­ing EHR sys­tems too pricey, providers say

Modern Healthcare - - THE WEEK IN HEALTHCARE - Joseph Conn

The cost of con­nect­ing one health in­for­ma­tion tech­nol­ogy sys­tem with an­other re­mains a sig­nif­i­cant bar­rier to achiev­ing the national goal of a com­put­er­ized and in­ter­con­nected health­care in­dus­try. Health­care providers com­plain that they of­ten pay high fees for th­ese in­ter­faces, which con­sist of soft­ware de­vel­oped and reused mul­ti­ple times by ven­dors of elec­tronic healthrecord sys­tems. Even some soft­ware de­vel­op­ers whose busi­nesses de­pend on those EHR con­nec­tions are un­happy about the high fees.

Michael Burkey, di­rec­tor of op­er­a­tions for the six-physi­cian Brad­dock Med­i­cal Group in Cum­ber­land, Md., said his pri­mary-care group has “got­ten killed” by in­ter­face fees. The group will pay about $5,000 to the de­vel­oper for an in­ter­face with a state pub­lic health reg­istry, and an­other $5,000 for a pa­tient por­tal, both Stage 2 mean­ing­ful-use re­quire­ments.

“Across the board, ev­ery­one I’ve talked to, it’s the same prob­lem,” Burkey said. “Providers with the same brand of EHR are go­ing to pay the same prices I paid.”

The prac­tice of charg­ing for in­ter­faces is ubiq­ui­tous in the health­care IT in­dus­try, said Mark Chris­tensen, a co-founder of We­bChartMD, a John­son City, Tenn., tech­nol­ogy ser­vices provider to mul­ti­ple med­i­cal tran­scrip­tion firms. Chris­tensen said he’s heard many com­plaints from his cus­tomers.

What with elec­tronic pre­scrib­ing, labs and other ser­vices, “the in­ter­face racket is pretty sig­nif­i­cant,” said Ja­son Mitchell, di­rec­tor of the Cen­ter for Health In­for­ma­tion Tech­nol­ogy at the Amer­i­can Acad­emy of Fam­ily Physi­cians. “I asked a ven­dor last year, ‘Why are you charg­ing our mem­bers $3,000 to $4,000 for in­ter­faces, and the on­go­ing cost of main­te­nance?’ ” The an­swer is “be­cause they can.”

With all the cri­te­ria im­posed on de­vel­op­ers to qual­ify their sys­tems for the fed­eral EHR in­cen­tive pay­ment pro­gram, “the cost of the EHR should in­clude all th­ese in­ter­faces,” Mitchell said. “Hope­fully, we’ll see some change com­ing, but I’m not hold­ing my breath.”

Not sur­pris­ingly, ven­dors see things dif­fer­ently. Dr. Jon Bert­man, founder and pres­i­dent of Amaz­ing Charts, an EHR de­vel­oper in North Kingstown, R.I., said his firm charges $5,500 for a high-level, HL7 in­ter­face to a lab and “for ad­di­tional con­nec­tions, we charge $500 for ev­ery prac­tice there­after. The $5,000 is for build­ing the soft­ware, the $500 for test­ing and de­bug­ging.”

But typ­i­cally those charges are paid by the labs, which want to use the IT in­ter­faces to bind them­selves to their cus­tomers, ac­cord­ing to Bert­man. Health in­for­ma­tion ex­changes have also been use­ful in spread­ing out the costs of lab in­ter­faces, he said.

“We never charge the doc­tor a fee,” said Girish Kumar Navani, CEO and co-founder of eClin­i­calWorks, a West­bor­ough, Mass.based de­vel­oper of EHRs for of­fice-based physi­cians. Lab or dic­ta­tion com­pa­nies pay for it be­cause they know they’ll make a lot of money from the physi­cian prac­tice down the line, Navani said.

“Why do in­ter­faces cost money?” Navani said. “I have a team of at least 135 sup­port peo­ple only sup­port­ing an­cil­lary sys­tems like labs, so it’s not in­ex­pen­sive. I don’t think we run the in­ter­face end on a for-profit ba­sis. We just see that there are enough re­sources to keep it go­ing.”

In its lat­est round of rule­mak­ing gov­ern­ing the EHR in­cen­tive pay­ment pro­gram, the Of­fice of the National Co­or­di­na­tor for Health In­for­ma­tion Tech­nol­ogy at HHS stopped short of re­quir­ing ven­dors to pro­vide all pos­si­ble in­ter­faces to qual­ify their sys­tems for par­tic­i­pa­tion.

An ear­lier ONC pro­posed rule on the test­ing and cer­ti­fi­ca­tion of EHRs would have com­pelled ven­dors to in­clude “clear pric­ing” on their web­sites and mar­ket­ing ma­te­ri­als re­veal­ing the full cost to pur­chasers of their prod­ucts in a sin­gle price. But EHR de­vel­op­ers op­posed the plan, say­ing it would hin­der in­no­va­tion and flex­i­bil­ity in prod­uct de­vel­op­ment.

In its Septem­ber 2012 fi­nal rule, the ONC re­tained price trans­parency as a guid­ing prin­ci­ple, but said EHR ven­dors would only be re­quired to “dis­close the types of ad­di­tional costs, and not the ac­tual dol­lar amounts of such costs.”

“We sug­gest providers, when shop­ping for an EHR prod­uct, ask the ven­dor or salesperson to de­tail all of the other add-on fees for which the provider will be li­able,” said ONC spokesman Peter Ashke­naz. “If the ven­dor is not up­front with those costs or

fees, please re­port the ven­dor ei­ther to ONC or the (cer­ti­fi­ca­tion body) and we will open an in­ves­ti­ga­tion.”

Some physi­cians are more san­guine about the in­ter­face fees. “We have a cou­ple of in­ter­faces that are up and run­ning that are very use­ful to us and a cou­ple more on the way,” said Dr. Eric Wei­d­mann, the HIT “cham­pion” at the South Austin (Texas) Med­i­cal Clinic, a group of nine fam­ily prac­ti­tion­ers that’s been live on an EHR since 2002.

Three of their in­ter­faces are to lab ser­vices providers, all with the more com­plex HL7 in­ter­faces. They are “well worth it,” he said. Two more are with in-of­fice de­vices, an EKG and a spirom­e­ter, and Wei­d­mann doesn’t be­grudge that ex­pense, ei­ther. “For a few thou­sand dollars, it’s worth it hav­ing a more so­phis­ti­cated, clean, timely sys­tem.”

But Wei­d­mann said they’ve de­clined of­fers to con­nect di­rectly with a lo­cal ra­di­ol­ogy group for a few thou­sand dollars. The ra­di­ol­ogy re­ports are still faxed over and scanned into the record, he said. To Wei­d­mann, an in­ter­face must be “highly use­ful” to war­rant the ex­pense of the in­evitable glitch re­pairs and up­grades down the road.

He has an idea of why ven­dors charge for in­ter­faces. “They’re do­ing their best to com­pete on up­front costs, be­cause doc­tors are no­to­ri­ously cheap when it comes to this stuff,” he said.

Kris­tine Drum­mond, CEO of Akron Com­mu­nity Health Re­sources, a three-site, feder-

“I asked a ven­dor last year, ‘Why are you charg­ing our mem­bers $3,000 to $4,000 for in­ter­faces and the on­go­ing cost of main­te­nance?’ ” The an­swer is “be­cause they can.”

—Ja­son Mitchell, Cen­ter for Health In­for­ma­tion Tech­nol­ogy at the AAFP

ally qual­i­fied com­mu­nity health cen­ter, said the high price of in­ter­faces cost an HIT ven­dor their busi­ness.

Drum­mond said her cen­ter wanted to con­nect the sep­a­rate EHR sys­tems for its den­tists and physi­cians. “We were go­ing to be charged an ad­di­tional $13,000,” Drum­mond said. “They were go­ing to have to have de­vel­op­ers on ei­ther end map my data.”

In­stead, the Akron cen­ter mod­i­fied some med­i­cal tem­plates on its physi­cian EHR for use by their den­tists and dropped the den­tal EHR.

Manuel Prado, pres­i­dent of Viva Tran­scrip­tion in Santa Cruz, Calif., said the high in­ter­face fees charged to physi­cians and hos­pi­tals have hurt his busi­ness.

“We had a hos­pi­tal in Iowa that was un­happy with their tran­scrip­tion com­pany and they wanted to switch to us,” he said. “But the ven­dor said to the hos­pi­tal that to switch would cost them $10,000.”

Rick Blume, man­ag­ing di­rec­tor of Ex­cel Med­i­cal Ven­tures, a Bos­ton-based ven­ture cap­i­tal firm, said the big­ger pic­ture that many EHR ven­dors ap­par­ently aren’t see­ing is that in­ter­op­er­abil­ity is good for busi­ness in the long term.

With EHRs, he said, “you’ve got cer­tain com­pa­nies try­ing to sal­vage their back­bone prod­uct” by in­creas­ing an­cil­lary rev­enues from things like in­ter­face fees, “in­stead of step­ping back and say­ing we’d be money ahead if we made this open ar­chi­tec­ture.”

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