Healthcare provider burden reduction and estimated cost savings realized with electronic case reporting implementation across 3 healthcare organizations

Abstract

Objective

Our study aims to assess the time-cost burden reduction of transitioning from manual case reporting to electronic case reporting (eCR) for COVID-19 among healthcare organizations (HCOs) over a 1-year period.

Materials and Methods

The study included 3 HCOs from different states with a total of 204 healthcare facilities that had a mixture of hospital and ambulatory providers. We conducted semi-structured interviews, data collection, and analyses of healthcare provider hours spent manually reporting COVID-19 cases along with hours spent implementing and maintaining eCR over 1-year periods. We calculated the time-cost burden of both manual case reporting, and eCR implementation and maintenance to assess the burden reduction of switching from manual to eCR.

Results

The number of provider hours reduced by switching from manual case reporting to eCR was 16 942 hours for HCO1, 14 145 hours for HCO2, and 2933 hours for HCO3. Burden reduction of provider hours that eCR offered translated into an estimated $827 120 for HCO1, $569 424 for HCO2, and $78 540 for HCO3, where HCO3 is a small, Federally Qualified Health Center.

Discussion

To our knowledge, this is the first time a nationwide information technology innovation was shown to directly reduce the administrative provider time burden and cost of manual case reporting on HCOs.

Conclusion

By automating patient case reporting, eCR reduced provider burden hours by at least 16-fold and cost savings of 4-fold or higher over a 1-year period.

Introduction

Healthcare provider burden

Provider administrative tasks are burdensome, taking up ∼50% of time that could otherwise be spent with patients.^1–3 One aspect of administrative provider burden is the reporting of possible cases of required conditions to state, tribal, local, and territorial (STLT) public health departments.⁴ Case reporting is a foundational component of public health surveillance, a process whereby healthcare providers report information with personal identifiers to STLTs for the purpose of surveillance, case investigation, including contact tracing and follow up. Case reports are submitted in compliance with legal mandates for reporting specific conditions to a public health authority.⁵

COVID-19 case reporting

The United States experienced significant numbers of confirmed cases and deaths from COVID-19, with over 100 million cases⁶ reported to public health agencies during the period it was designated as a nationally notifiable disease⁷ and, as of December 2024, contributing to over 1.2 million deaths.⁸ The pandemic placed an unprecedented burden on the healthcare system as well as the economy. In the United States, public health laws governing case reporting vary by jurisdiction with STLTs having broad authority to collect case reports from healthcare providers for disease prevention and control efforts.⁹ Case reporting often occurs at the time an illness is confirmed by a clinical laboratory result but may also occur when an illness is suspected by a provider.¹⁰ Providers historically sent patient case reports to STLTs using manual methods (eg, fax). Manual case reporting is often slow, results in incomplete data and places a substantial amount of work on healthcare providers and public health practitioners.^11,12 Provider burden increased significantly during the pandemic, leading to the need for a nationwide health information technology solution that automated case reporting from providers to STLTs. Studying COVID-19 case reporting provider burden may help elucidate processes to alleviate burden and position the US for improved response readiness.

Electronic case reporting

An innovation in case reporting is electronic case reporting (eCR), the automated generation and transmission of case reports from electronic health records (EHRs) to STLTs for review and action.¹³ eCR is a partnership among the CDC, the Association of Public Health Laboratories and the Council for State and Territorial Epidemiologists.¹⁴

As of February 21, 2025, eCR was implemented by 74 health departments, including all 50 states, District of Columbia, 3 territories (Puerto Rico, Guam, American Samoa), 17 local jurisdictions and 3 Tribal jurisdictions. Over 50 300 healthcare facilities were sending case reports to STLTs (Figure 1).¹⁵ Healthcare facility data was sent electronically from hospitals, urgent care centers, nursing homes, schools, and clinics to STLTs.

Figure 1.

Healthcare facilities sending automated eCR data over time. The dots on the maps indicate the location of healthcare facilities connected to the eCR infrastructure. The map on the left demonstrates that on January 27, 2020, there were 187 facilities representing 2 HCOs using eCR to send case reports to public health departments. The map on the right demonstrates that on February 21, 2025, more than 50 300 facilities representing 4916 HCOs were using eCR.¹⁵

Populations

The use of eCR is far-reaching, including use by rural critical access hospitals (CAH), tribal health clinics, and Federally Qualified Health Centers (FQHC). As of January 5, 2025, there were 47.9% of rural CAH (653/1362) and 17.7% of FQHCs (2440/13 801) nationwide sending eCR data to STLTs. FQHCs are funded by the Health Resources & Services Administration to provide care to hard-to-reach populations, including front line workers, residents of public housing, individuals experiencing homelessness, and farm workers.¹⁶

Related work

The timeliness, completeness, and outbreak readiness benefits of switching from manual case reporting to eCR have been documented in published literature.^{13,14,17–20} A recent study demonstrated the eCR return on investment (ROI) for STLTs,²¹ and for one healthcare organization (HCO),²² however, our study is the first to document the eCR time-cost burden reduction for healthcare.

Objective

In this article, we discuss the following impacts of eCR implementation for 3 HCOs: (1) time burden reduction of healthcare provider hours compared with manual case reporting; and (2) cost burden reduction for HCOs relative to manual case reporting. Further, (3) we describe the current number of STLTs that have authorized discontinuation of manual case reporting for HCOs in their jurisdictions to understand the potential larger impact of eCR adoption on time and cost burden.

Methods

Method overview

We measured the HCO time-cost burden reduction for both manual case reporting along with eCR implementation and maintenance over a 1-year period. Three HCOs from different states with varying numbers of healthcare facilities, HCO1 (130 facilities), HCO2 (52 facilities), and HCO3 (22 facilities) participated in the study, where HCO3 was an FQHC. All HCOs used Epic²³ as their EHR system, which they already had in place prior to implementing eCR. Therefore, EHR vendor efforts were not measured. Study periods for HCO1 and HCO2 were between March 2020 and March 2021, whereas for HCO3, the period was between April 2020 and April 2021.

Both HCO1 and HCO2 had in-house informatics departments that implemented eCR, whereas HCO3 partnered with a non-profit health care innovation center for eCR implementation. All 3 HCOs sent COVID-19 case reports to STLTs and switched from manual case reporting to eCR for COVID-19.

Data collection

Following a semi-structured interview using a collection instrument (Appendix 1) for manual case reporting and eCR, each HCO self-reported the staff involved in terms of their equivalent titles using the Occupational Outlook Handbook from Bureau of Labor Statistics (BLS).²⁴ State public health departments were invited to attend interviews with HCOs in their jurisdictions. Raw data for eCR included staff member title, the number of staff involved, the proportion of time during a 40-hour work week and the number of weeks to implement eCR, or the total number of hours used by staff for eCR implementation. Raw data collected for manual case reporting included the staff member title, the number of staff involved, type of manual case reporting, time in minutes for type of manual case reporting (eg, faxing, and web form), and the number of COVID-19 cases reported. HCOs reported both suspected and positive (laboratory-confirmed) cases during the period, as requested by each of their state public health departments. HCOs also reported cases that were suspected but tested negative (laboratory-confirmed) as negative cases. Additionally, we requested information on whether any additional materials or equipment were purchased during the period solely for manual case reporting.

Data analyses

The costs of manual case reporting were attributable to the labor cost of healthcare provider staff dedicated to reporting cases manually. The cost of eCR implementation and maintenance accounted for the labor cost of staff involved in eCR planning, implementation, and maintenance over the period.

Manual case reporting

Time-cost for manually reporting COVID-19 cases over the study period was calculated using the (1) number of COVID-19 cases reported, (2) the time to report cases manually, (3) aggregated by the method of manual reporting converted from minutes to hours (Appendix 2A). Paper/fax refers to the hand filling out a paper form and faxing it to the public health department for reporting. The cost of manual case reporting was estimated using the mean wages of 2020 and 2021 in BLS per hour by the involved staff and the provider hours used for manual case reporting. As an example, an HCO provider (eg, registered nurse) sent a total of 1000 reports and used 10 minutes of time to fill out and fax each report to the state public health department (Table 1).

Table 1.

Example method for time-cost calculation before adjusting for inflation for a registered nurse.

Manual case reporting method	Study period	Time to report (minutes)	# Reports	BLS labor cost per hour ($)	Labor cost before adjusting for inflation ($)
Paper/fax	March 2020-March 2021	10	1000	37	6142

A registered nurse spent an average of 10 minutes filling out and faxing one case report (10 minutes/report) sending 1000 case reports over the study period (× 1000 reports)/60 minutes = (166 hours reporting × $37/hour BLS staffing labor cost for a registered nurse) = $6142 labor cost spent by an HCO during 2020-2021 before adjusting for inflation.

The hourly wage estimate was calculated using the median income from BLS converted to its hourly rate. The manual case reporting cost for each BLS title (eg, registered nurse) was calculated using the total number of labor hours for each BLS title for manual case reporting with its corresponding BLS hourly income rate. Added together, the BLS title costs provided the total cost of manual case reporting for each HCO.

Electronic case reporting

The time-cost of electronically reporting COVID-19 cases over the period was calculated using the (1) time spent implementing and maintaining eCR and (2) the mean wage of years 2020 and 2021 in BLS of the involved staff. HCOs were asked to provide the time staff used for eCR implementation and maintenance by staff member BLS title.

For eCR maintenance, HCO1 tracked the time-cost data over the 1-year period and provided this information to the study team. HCO2 provided an estimated amount calculated using the time (labor hours) staff used to maintain eCR. HCO3 used a health information network that provided an estimated amount calculated using the time (labor hours) staff used to maintain eCR. The hourly wage estimate was calculated using the median income from BLS converted to its hourly rate. The eCR implementation cost for each BLS title was calculated using the number of labor hours for each BLS title and its corresponding BLS hourly income rate. Adding all the BLS title costs together equaled the total cost of eCR for each HCO.

We also requested information on whether any additional materials or equipment were purchased during the period solely for eCR.

Calculating for inflation

Due to changes in cost of living reaching 21.9% nationwide from March 2020 to September 2024, our time-cost estimates were adjusted to reflect inflation. Inflation was calculated using price index, seasonally adjusted consumer price index-urban (CPI-U), including all items in US city average.²⁵ Additionally, regional differences of price increase were estimated using regional CPI-U (Midwest for HCO1, South for HCO2 and South for HCO3). Because reported cases spanned 2020 and 2021, the cost totals for 2020 were adjusted for inflation using CPI-U from March 2020 to September 2024, and the cost totals from 2021 were adjusted using CPI-U from March 2021 to September 2024.

Calculating burden reduction

The time burden reduction in provider hours was calculated as the difference in hours between manual case reporting provider hours minus the hours to implement and maintain eCR for each HCO. The cost burden reduction in USD was calculated as the difference in cost of staffing labor required for manual case reporting minus the cost in staffing labor to implement and maintain eCR, adjusted by inflation.

Discontinuation of manual case reporting

Once an HCO implements eCR, there is a period of parallel reporting where the HCO reports cases both manually and using eCR. Once eCR data quality has been validated by the STLT with the HCO, the STLT may then authorize HCOs in its jurisdiction to turn off manual case reporting and use eCR exclusively. As of February 2025, the method for assessing nationwide discontinuation of manual case reporting is public health jurisdiction self-reporting through the CDC-funded cooperative agreement, Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases (ELC), Health Information Systems.²⁶

Results

Time-cost calculations were performed for manual case reporting (Table 2) adjusted by inflation (Appendix 2).

Table 2.

HCOs time-cost calculation for manual case reporting.

HCO	Method of reporting	Time to report (minutes)	# Reports	Labor hours total	Labor cost per hour ($)a	Labor cost before adjusting for inflation ($)a	Total labor cost before adjusting for inflation ($)a	Labor cost after adjusting for inflation ($)a
HCO1	Paper/fax	12.5	4822	1004.58	41.38	41 569.66	707 668.69	840 634.16
HCO1	Web Form	7.5	128 777	16 097.13	41.38	666 099.03
HCO2	Web Form	25	35 100	14 625.00	41.38	605 182.50	605 182.50	718 891.61
HCO3	Web Form	15	12 480	975.00	17.75	17 306.25	82 988.10	98 585.12
				1170.00	24.08	28 173.60
				975.00	38.47	37 508.25

^aTime-cost calculated for manual case reporting type by HCO. Results are approximated to 2 decimal points. HCO3 had 3 BLS distinct titles doing manual case reporting.

Time-cost calculations were performed for eCR (Table 3) adjusted by inflation (Appendix 2).

Table 3.

HCOs time-cost calculation for eCR.

HCO	Method of reporting	Labor time used for implementation (hours)	Labor time used for maintenance (hours)	Total labor cost for implementation($)a	Total labor cost for maintenance ($)a	Total labor cost before adjusting for Inflation ($)a	Total labor cost after adjusting for inflation($)a
HCO1	eCR	160.00	NA	8086.15	3000.00	11 086.15	13 514.07
HCO2	eCR	480.00	603.20	53 312.54	69 301.80	122 614.34	149 467.42
HCO3	eCR	480.00	80	12 089.42	4354.13	16 443.55	20 044.76

^aResults are approximated to 2 decimal points.

Burden reduction

Over the period, the time spent manually reporting cases for HCO1 was 17 102 hours vs 160 hours for eCR. HCO2 used 14 625 hours for manual case reporting and 480 for eCR. HCO3 used 3120 hours for manual case reporting and 187 hours for eCR. The reduction in provider hours offered by eCR for HCO1, HCO2, and HCO3 was 16 942 hours, 14 145 hours, and 2933 hours, respectively (Figure 2).

Figure 2.

Comparison of switching from manual case reporting to eCR for 3 HCOs in term of hours over a 1-year period for COVID-19. HCO, healthcare organizations. HCO1 represent 130 facilities, HCO2 represent 52 facilities, and HCO3 represent 22 facilities, where HCO3 was an FQHC.

The cost spent manually reporting cases for HCO1 was $840 634 vs $13 514 for eCR. HCO2 cost for manual case reporting was $718 892 compared with $149 467 for eCR. HCO3 cost for manual case reporting was $95 585 vs $20 045 for eCR. The reduction in cost offered by eCR for HCO1, HCO2, and HCO3 was $827 120, $569 424, and $78 540, respectively (Figure 3).

Figure 3.

Comparison of switching from manual case reporting to eCR for 3 HCOs in terms of cost over a 1-year period for COVID-19. HCO, healthcare organizations. HCO1 represent 130 facilities, HCO2 represent 52 facilities, and HCO3 represent 22 facilities, where HCO3 was an FQHC.

Additional materials

None of the 3 HCOs self-reported purchasing any additional materials or equipment during the period for either manual case reporting or eCR.

Discontinuation of manual case reporting

STLTs conduct data quality testing with HCOs in their jurisdictions for various data streams, including eCR. The 3 state public health departments worked with HCO1, HCO2, and HCO3 to test and validate eCR data quality for COVID-19. The STLTs authorized the 3 HCOs to turn off manual case reporting and use eCR exclusively for COVID-19 effective March 2021 for HCO1 and HCO2 and, April 2021 for HCO3. Nationwide, STLTs have authorized the discontinuation of manual case reporting for 12.3% of HCOs, allowing eCR-exclusive reporting across all reportable conditions as of March 2025.²⁶

Discussion

Burdensome administrative tasks, including manual case reporting (eg, completing paper forms and faxing), are taking up ∼50% of provider time that could otherwise be spent with patients.^1,2 EHR systems may also lead to clerical provider burden.^3,27 Our study is, to the best of our knowledge, the first to demonstrate a decrease in healthcare provider burden offered by eCR, a growing health information technology innovation that provides an alternative to manual reporting.

In this study, we worked with 3 HCOs (204 facilities) to evaluate provider hours spent on manual case reporting and labor cost vs eCR for COVID-19 over a 1-year period (Appendix 2). We included an FQHC, which provides care for hard-to-reach populations. For all 3 HCOs, the reduction in provider hours when switching from manual case reporting to eCR ranged between 16 and 160 times, and the cost reduction was between 4 and 61 times in savings.

Our results suggest that adoption of eCR can lead to significant burden reduction for providers and cost savings for HCOs, especially in the context of an outbreak where both suspected and positive (laboratory-confirmed) cases must be reported. The reduction in provider hours may represent time that providers could have otherwise spent with patients.

Additionally, the savings associated with implementing eCR can extend beyond the initial investment, because of the scalability of eCR. As of February 2025, eCR scaled beyond COVID-19 to include 225 other conditions required to be reported to public health, creating a multiplier effect on the savings. A multiplier effect results when a relatively small change in one economic factor (eg, eCR implementation) induces a disproportionate decrease in another (cost savings).²⁸ A recent study in an academic healthcare setting showed eCR’s multiplier effect by evaluating the economic impact of expanding eCR beyond COVID-19 for 29 reportable conditions revealed a strong ROI for STLTs.²¹

The full benefit of burden reduction for healthcare requires the ability to phase out manual reporting processes. To achieve this, public health agencies must have the necessary infrastructure to effectively leverage data that originates from healthcare for public health use. The centralized infrastructure available through intermediaries, such as the Association of Public Health Laboratories Informatics Messaging Service platform used in this instance²⁹ can help reduce the technical and operational burden on individual jurisdictions while improving readiness for phasing out manual reporting processes.

Out of the more than 50 000 HCOs nationwide, only 12.3% were able to discontinue manual reporting as of March 2025.²⁶ CDC recognized the importance of provider burden reduction by creating a 2025 Public Health Data Strategy milestone, eCR reduces manual reporting from healthcare.³⁰ Additionally, public health departments receiving ELC funding are required to report on the number of HCOs authorized to discontinue manual case reporting in their jurisdictions. The wide adoption of eCR and the discontinuation of manual case reporting could represent major cost savings for public health that are yet to be estimated.

Limitations

Our study is limited by a small sample size that may not be representative of all US HCOs, varied in numbers of facilities, which may have impacted the cost differences, and HCO self-reporting on the time spent in manual case reporting. Also, the HCOs studied all used the same EHR system (Epic); EHR vendor use, and implementation may vary across HCOs. Despite these limitations, our findings demonstrate a time-cost burden reduction offered by eCR. Future studies could include larger and more diverse samples of HCOs to validate these findings. Additionally, investigating the potential barriers for STLTs to allow the discontinuation of manual case reporting in their jurisdictions could further elucidate why only 12.3% of HCOs nationwide were allowed to stop manually reporting cases.²⁶

Conclusion

The eCR burden reduction advantages are (1) providers can redirect their time from filling out and sending manual case reports to taking care of patients, (2) reduced costs for HCOs, and (3) eCR is a 1-time implementation with (4) low maintenance costs.

eCR was previously shown to improve both the timeliness and completeness of patient case reporting. This is the first study showing a time-cost burden reduction for healthcare providers and HCOs offered by eCR. Once an HCO is sending quality data via eCR, the full value of HCO burden reduction depends on STLTs allowing them to cease manual case reporting. Further, while our findings were limited to a single reportable condition, the benefits of switching to eCR are applicable to other diseases of public health importance, serving as a scalable response-ready nationwide solution.

Author contributions

Oscar Rincón-Guevara (Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing—original draft, Writing—review & editing), Abdulhakeem Olorukooba (Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing—original draft, Writing—review & editing), Grace S Eau (Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing—original draft, Writing—review & editing), Matthew D Ritchey (Conceptualization, Funding acquisition, Methodology, Project administration, Resources, Supervision, Writing—review & editing), Laura A. Conn (Conceptualization, Funding acquisition, Methodology, Project administration, Resources, Supervision, Writing—review & editing), and Kimberly Knicely (Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing—original draft, Writing—review & editing)

Supplementary material

Supplementary material is available at Journal of the American Medical Informatics Association online.

Funding

Fellowships: Author Oscar Rincón-Guevara received support during the initial 2 years of the study through the CDC Steven M. Teutsch Prevention Effectiveness Fellowship. Author Abdulhakeem Olorukooba received support through the CDC Public Health Informatics Fellowship Program. Author Grace Eau received support during the initial 1.5 years of the study through an inter-agency agreement between CDC and the Department of Energy, Oak Ridge Institute for Science Education (IAA 20FED2000398OS1).

Contracts: The maps depicted in Figure 1 were funded through 2 CDC contracts on the blanket purchase agreement for Geospatial Research, Analysis, and Services Program (GRASP) to DRT Strategies, Inc. (contract task orders 75D30118D01974 and 75D30123A15958).

Conflicts of interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability

The authors confirm that the data supporting the findings of this study are available with in the article and its supplementary materials.

Disclaimer

The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of CDC.

Institutional review board review

This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy (45 CFR part 46, 21 CFR part 56; 42 USC §241[d]; 5 USC §552a; 44 USC §3501 et seq). Institutional review board determination was not required because the study did not involve research among human subjects and was conducted as part of public health surveillance. CDC project determination number 0900f3eb81febae4.