EHR’s Role in Population Health Management: Q & A with eClinicalWorks CEO Girish Navani

Accordingly to a recent survey of 18,575 physicians across 25 specialties, 40% of physicians do not use an EHR because EHRs interfere with the doctor-patient relationship. Patient engagement has been a difficult concept for most EHR vendors and developers to grasp leaving providers frustrated with their EHRs meeting the Meaningful Use Stage 2 criteria.

Girish Navani, the co-founder and CEO of eClinicalWorks, a provider of ambulatory HIT solutions, sat down with Medscape's Erica Garvin to discuss the challenges of managing care coordination and patient engagement.

Q. Let’s start by talking a bit about your professional background; I know you have experience in semi-conductors and finance, but have been involved in HIT for more than 15 years now. Tell me how your experience in HIT led to the success of eClinicalWorks?

My background is technology, and it has been for about 25 years now. eClinicalWorks, the idea of it and HIT, came to life when I was in a conference in Europe and heard some presentations made around the future of Healthcare and technology. That vision appealed to me. I took a lot of my understanding of how to take digital systems that we were building at finance and other companies like Aspen and see what we could do to make it apply to a healthcare system, where we would connect the consumer’s healthcare to the suppliers healthcare and digitize the whole system. The last 15 years have been about putting one brick on top of the other, trying to make that vision become real.

Q. Right. And it seems like you had that vision far before the HITECH ACT. Does that vision attribute to the success of eClinicalWorks in any way? Do you think that you saw what was happening before some of these other vendors who later came out of the woodwork?

That is very true, HITC. If you look at our company inside, what we have been focused on, it’s been about digitizing the entire spectrum of healthcare, from the consumer down to the doctor. Electronic health records is one big piece of that, but so is the patient engagement side, and so is the analytics. It’s just been a matter of prioritizing which piece came before the other while we’ve been working architecturally and on a product vision that would indeed meet that entire supply chain.

Q. Right. And that plays in nicely to this question: There is a lot of ambiguity about the ROI in relation to EHRs as of late, especially for those providers now trying to attest to the more stringent criteria of MU, Stage 2. Some feel that they have nothing more than a sophisticated billing system. With that in mind, how has eClinicalWorks managed to have been different with its product? It seems that you have been able to capture engagement on both the provider and patient side. How have you done that? Has that attributed to your success?

Correct. I think you’re right. Provider engagement is one of the big compliments there. We have been listening to our customer base extensively, and understanding their work-flows, and understanding how they use technology, and make sure that we build software that meets those needs. The second part is how you deploy it. I think we’ve leveraged cloud computing very extensively since 2003, which has made a difference. At least in today’s day and age, deploying both product and content over the internet is important.

Making it available on different form factors like smart phones, iPads, PCs, tablets, has been the other benefit. The products support this different modality of being cloud-based, very mobile, which supports the notion of having intuitive design, which leads to a higher level of physician satisfaction, which I think is the first step to then go focusing on population and patient, because if a physician is not going to use technology in their office, then the second two steps really won’t have a meaning.

So a lot of systems don’t meet that criterion. They are sophisticated billing systems that really don’t lend themselves to mobility. They don’t lend themselves to different form factors of use. Their user interface is not designed with the physician in mind. So if the end user feels that they’re not justifying the ROI, and then to top it off, these companies do not have the other solutions for managing population and patients, you really don’t get the full value for what you’re putting your money into.

Q. Absolutely. And I want to get to that whole aspect of managing the population. But before we get there: you just brought up being intuitive to physicians. I understand that to connect with physicians, eClinicalWorks really took the time to understand the way not just one physician but multiple clinical workers operate by producing multiple interfaces. Can you tell me how you arrived at that solution?

We hopelessly hone in on every single customer request. We actually have two online forums of user communities where our users can voice an opinion of what they’d like to see in the product, and then others get to vote on what they feel is important. We take the ideas that get commonly voted on and we develop them. That’s one. Second, we’re open to critique. We don’t mind being told what we don’t do, even if that information is available to a competitor, which lends ourselves to be more agile in meeting needs and requirements. Even to date, I still get told every single day, “You don’t understand what a physician really wants.” I still take that as a compliment.

So different ways, different modalities of listening every day, watching them use, develop it, and don’t get too nervous about critique. Try and incorporate that in the next iteration of your product.

Q. Right. So what do you say to those who don’t think that EMR/EHR technology is up to snuff, especially for accountable care organizations (ACOS), which are really something that you have had success with, especially when it comes to patient outcomes? We’ve been talking about this whole idea of not only just recording billing, but having a solution that not only works for the intercommunication of an ACO, but does by and large, manage the population and help you practice population health management. Talk to me a little bit about how your technology is achieving that and overcoming the speculation that it isn’t sophisticated enough for that purpose?

Well, in 2007, we did a very large community project in the city of New York. The goals were extensive: improve the healthcare for six million patients in the city by deploying technology to 3,200 primary care doctors. That as a goal is very large. We looked at the learning we’ve gotten from that over the last seven years, and I think that’s made us understand population health better than many other companies and many other products. It starts with the deployment of an intuitive electronic health records system, but it does not stop at the deployment of electronic health records systems.

You have to build technology that sits on top of an electronic health records system. For example, analytics: being able to take data from many different practices and collate it in such a way that you can make better decisions. We have a very strong analytics layer now that we developed as part of our population health management.

From thereon, you need to go ahead and identify patients that need interventions and that need some form of coordinated care, which then allows you to have a layer of technology that can be used by, I call them “intermediary layers of care,” like nurse managers, coordinators, dieticians, nutritionists, so that you can counsel the patient. If the patient does not do well, then you get the PCP engaged even more. That learning is now a part of solution. It sits on top of our EHR.

I might actually be the one to tell you that our EHR alone will not improve population health, but our EHR combined with our care management capabilities and product line will help improve population health. We have demonstrated that across the country. We have a number of ACOs, as you now know, that leverage both our pieces; they leverage our EHR, they leverage our population health management product. The two together improve quality of care in a big way.

Q. With that in mind, if you’re working with an organization, is the adoption of the technology a tiered process, or would you install both products at once?

You know, we would like to do both at once, but it is not easy to do both. You’ve first got to get a physician to a level of understanding how to use an electronic health records system, so they can do the prescription writing, ordering of the labs, understanding their vital signs, and focus simple alerts and simple interventions. Population health should come right after that so that you can then start focusing on telling them what they need to focus on more: where are the areas of concern in terms of their population, what interventions might work. So I’d put it as a two-tiered product.

Now, if you are converting a customer from one EHR to eClinicalWorks and they’re already familiar with the use of an EHR, than that might be a much shorter cycle. You could go “bang bang,” and do it back to back, while if you’re coming from a paper world, you might take a little bit longer. You might first do the EHR, pause a little, and then do population health management.

Q. Right. So what do you say to the people that feel like their current product isn’t up to snuff then? I think some providers feel it’s discouraging to think that the upfront investment and training isn’t paying off and it’s really not being successful. Do they have to, in a sense, start from scratch?

No. In a number of ACOs in the country, we have physicians on disparate EHRs. We are still succeeding with population health management for them. Now, I’m not saying it’s as easy as having an EHR from eClinicalWorks on the other endpoint, because there we do integration as well, which is because we put the data right into the physician’s inbox. But, you do not need to abandon your EMR just to use eClinicalWorks population health tools. You get an added benefit if you are using both, but we have many ACOs today that don’t. In fact, we have some that don’t use our EHR at all. They still use our population health management tools.

Q. Right. So, why the focus on ACOs? Why not other aspects or other health institutions?

No, I think we’re doing all of the above, HITC. That’s the point I want to highlight, that Medicare shared savings program a la ACO is not the only quality and risk program that we’ve achieved success in. We have many customers doing Bridges to Excellence as one of the other programs. We have many customers doing commercial insurance plans where they’re getting into this.

We have a large network in Minnesota that is doing Blue Cross/Blue Shield Minnesota children’s initiatives, which is clearly not Medicare. So these are board highlighted ACOs where we are leading in terms of both market share and functionality, but that same functionality has been used for other programs, including pediatrics. We are getting into
orthopedics and Ob/Gyn also, so it’s diverse to handle not just primary care, it’s also got the flexibility of dealing with other payer programs.

Q. Right. OK. Back to talking a little bit about the population health management aspects: We talked about how important it is to engage the physician, but part of the piece of the PMH pie is certainly patient engagement. So obviously, how does your technology gear staff to engage with the patient, because that is a key piece of the puzzle here?

I don’t know if you read that press release, but if you didn’t, I’ll send it your way. Two years ago we decided to invest a substantive amount of money. We had set $25 million at that time. We have since added to that investment where we would hire people, we would have eClinicalWorks resources start a new subsidiary with exclusive focus on
building software technology for patients to use. It’s called healow, Health and Online Wellness.

As part of an initiative of the last two years, we came up with a healow app which has been extremely successful. Their patients download it, they get access to their own records, they can talk to doctors, they can enter their own vital signs and all. We have since then launched in Dallas, and we’re going to go nationwide soon, which allows patients to find new doctors for care if they have not been able to find one yet. It’s a platform to find resources. When you do that, you automatically get access to your healthcare if you go visit that doctor because you get your electronic health records converted to you in a PHR form.

We are now launching in the summer Telemedicine. We are going to come out with integrations for Fitbit and other wearables. I have a whole division in the company with significant resources both in terms of money and people that are heavily focused on building technology that we want patients to use when they are at home, and find ways to engage doctors by either doing real time visits like telemedicine or get notified with text messaging/voice messaging reminders, or being able to find healthcare services when they’re looking for new ones.

Q. Right. I think it would be interesting for our provider readers to get a little of your insight on what is it that the patients are looking for when it comes to connecting with a health institution or with any matter of their own health on a device? What has the conversation largely wrapped around itself there?

I think we can share more. The most common thing we are seeing right now is that there’s a generation of patients that like smart phones and smart phone apps. There’s a generation that prefers to be notified with voice and text and reminders, and there’s a generation that likes voicemail still, a phone call right into their home. I think it’s different modalities based on different people and different needs. I think the best way we’ve done it, is we’ve allowed a patient to make the modality or pick the modality that they like most and have their provider engage them using that capability.

Q. Right. Now, with population health management, a lot of our aging population, that plays into it, especially with disease prevention. They may not, well, there are plenty of tech-savvy people that are in the aging population, but how do you address that challenge?

It’s not easy. I think that’s why you will find the use of care coordinators, care managers: people that will engage patients when they’re at home. I think technology will facilitate who they need to call, who they need to talk to, and what they need to overcome in terms of their barriers or goals that they’ve had. But you might not just have technology do it. It’ll be technology plus human intervention, but it will still not require an everyday visit into the office. You could do that with a patient still being at home.

Q. Right. That brings me to the question of: how much or how important is the human element here? Like you said, you talk to doctors on a daily basis that still say, “You don’t understand our needs.” I think the flip side of that is, sometimes people rely, maybe, on the technology too much without perhaps thinking of the mastery of the technology, or how to fully integrate the technology into their practices. What’s your thought on that?

I think technology will facilitate and assist. The technology will not displace the use of the healthcare professional being the quarterback of care. I just think that if you’re in a paper-based system, the healthcare provider will not be able to do it, because they
won’t even know who to reach out to, when is the next follow-up that they should make, and can I leverage technology to do it, or also do it on an exception basis.

For example, you tell a patient to give us their weight, and they give you their weight profile regularly, and only when they gain weight and they’ve been diagnosed with congestive heart failure, you might find the need to call them. So instead of calling them 10 times, you might call them once and counsel them and work with them. Technology will play a role, but it will never be at the expense of not having a healthcare quarterback. I’d go as far as to say that there’s a reason why Microsoft HealthVault and Google Health failed, and that’s because there was no doctor behind those patient engagement platforms. If there is a healthcare provider like this, in on our case behind healow, you will have patients using that platform.

Q. Interesting. With that in mind, can you talk to me a little bit about what are some of the challenges that come with instituting that population health management, and what are the takeaways, the lessons learned in working with those providers that you have learned to help them do that?

There is a significant amount of change in moving fromfee-for-service to fee-for-value. There’s a significant change of mindset in terms of understanding how you might end up actually not making the same amount of revenue if you don’t achieve your goals, and how do you collectively have each provider get into that mindset? That’s the hard part. That’s the counseling part of getting together. What we have found easy or easier is finding the cost saving while attaining better quality goals, because there have been significant savings that can be accomplished.

I have a number of ACOs that have talked about readmission to hospitals dropping somewhere between 12-17% after they put the technology in, and after they started proactively managing patients that were being discharged. There have been reductions in duplicate labs being ordered, because lab results were available once and they could all see it.

There were many lessons learned by stratifying patients that were high-risk versus low-risk, focusing more attention to the high-risk patients and addressing them proactively which resulted in lower admits to inpatient settings.

That’s not the hard part, because once you get to see the scorecards, physicians, like any, are very competitive. They get to do it, they get to change. It’s the initial step of moving in that direction which is the harder part, and that’s an area that I think we will have to continue to work towards that physician networks need to come together to attain better quality outcomes, and they’ll have better cost savings as well.

Q. Right. So, if you’re sitting down across from a hesitant physician or provider organization, what do you say to them to try to get them on board?

I think the best way to do it is to have them talk to another physician that has done it, and ask them the lessons learned, and see the benefits they got, and also understand that is inevitable, that that’s where we need to go. The sooner we start that discussion, the better it is. It is going to take hard work, but I think we are building enough of a reference base where we can have one customer help the other go through it.

Q. Right. And I understand that is how eClinicalWorks has had their success, that it has its own social media group where physicians were suggesting the product, but it wasn’t actually an eClinicalWorks site. Am I correct on that?

That is correct. It has always been that model: un-moderated, uncensored view to your customers with the overview where they can talk to others. For every one that might walk away because they see our weaknesses, nine accept it and embrace it and move forward because they know more than they ever did. That’s pretty much how we run the company. Our salespeople are our customers.

Q. Right. Another unique thing is that you haven’t changed your price point. Why is that? What’s the thought process behind that?

We are able to run a very profitable company at the price point by just getting more customers to go with us. Plus, we are a cloud-based solution, so we have a lot of recurring revenue stream. We don’t have to raise prices to survive, so we won’t raise it, because the goal is not to just make more money. The goal is to find a way to improve healthcare, for which we need more doctors to use technology, which means if I can make it more affordable, I will. I will tell you that every one of my customers will tell me, “You’re still trying to charge me too much,” but we haven’t changed the price over the last 14 years.

Q. So, what is the thought process as you develop your products, especially when you were developing your population health management solution?

I think our philosophy has been very straightforward. You try to get your customers to get an affordable product at a price point that they will probably find acceptable. Keep it consistent. Don’t go back to them and raise it after they buy the product. Find a way to build efficiency in your own business models. I think it’s worked for us the last 15 years. I think it’s going to work for us another 15 years.

Q. We’ve talked about the technology and we’ve talked about the human element already, but I also know that in your own organization, you’re known for your leadership skills, so there’s something I want to ask about. How much does eClinicalWorks get involved to offer that helping hand to put the organizational structure in place to make that transition from fee-for-service to practicing population health management? I would imagine that’s a really important part of it, and I didn’t know if you guys offer a hand in that in any way.

I think that’s a great question. We’ve so far gone to the point where an organization has decided to be a fee-for-value, and we provide them a lot of consulting and a lot of help on what they should do after, in terms of both technology and how to leverage it, and what changes to bring in at all. There’s a step before this too, which is proactive consulting and management services on how to get there. We’ve not been in that space as a company. We have actually helped our customers. There are some that actually manage multiple ACOs. There are some that have actually gone ahead and built clinical integration companies to help. We’re right now working that through a partner program. The question remains open: Will we ever get into the upstream process as well? I am not sure about that at this moment in time.

Q. Right. I do want to ask you about, not to speculate too much about what’s really next for eClinicalWorks, but before get there, I do want to ask a more general question. Obviously the technology is really developing where now, especially with the emerging importance of population health and wearable technologies etc. With all those things are coming into play, what trends or what do you think is going to develop over the next, say, 5-10 years? How is technology going to continue to change this landscape?

I think it will change the definition of an electronic health record over the next five years. An EHR that does not do patient engagement and population health as a core competency won’t be the electronic health record of the future. That transition is going to be the fun one. That transition from moving from what I would call a meaningful use compliant EHR to a capability that does manage populations, engages patients, digitizes the entire system, allows a provider to talk to another provider, allows a lab company to distribute lab results directly to patients; that entire ecosystem connected, transparent, cloud-based; gone from selling products and services to an ongoing monthly model of use technology is where you will see the trend moving.

You will also see the status quo challenged in a big way. The priority will become the patient because they’ll be the consumer of care, and the employer that foots the bill of care, and technology that serves purposes for employers and patients will dominate more conversations than the ones that do the inpatient systems.

Q. Interesting. This is just an additional question I had listening to what you were just saying. Do you think that MU, although well intended has led some providers astray on what the real meaning of these products are? Do you think that that had any part or any negative impact on what we’re seeing now?

Most certainly. There was an artificial deadline with an artificial incentive to get paid. People will make decisions without the proper due diligence. That’s not just applicable to healthcare. That would apply to anything. So, yeah, I think that decision-making has happened, and I think we have seen that a worse thing of that as well as we go into it. 70% of our business now is coming from customers that are on a different EHR, so I do think that trend will continue.

I also think that you will see a far fewer number of vendors standing within five years. I also think that the government will be more involved in our industry, not less. Our company will have to figure out how to balance those two: how to keep our customer happy while meeting government mandates, which I don’t think are the easiest or the most efficient, sometimes, in their deadlines and their priorities. You’ve just got to manage it.

Q. Right. With that in mind, another similar question: We’re calling this at HIT Consultant the year of the patient engagement. I think by and large that’s really what’s happening. People are really waking up to the fact that patient engagement is where it’s at, because obviously provider engagement is key, and the success of these solutions are riding on that.

Also, the success as to how you engage with the patient. You talked greatly about how your company is making those strides through the wearable apps, through all those applications and whatnot. My question to you is: why do you think it has taken so long to consider the patient? That’s sort of like it was the last consideration when it came to technology, maybe not for you, but maybe the consensus out there.

There was no incentive. The incentive has only come over the last few years. We built it many years ago. Our patient portal started in 2003 if not before that, actually. In 2003, we were actually used by customers. You asked me the question, “Why are we thinking about it now?” Because now many patients are getting into high deductible health plans (HDHPs). Patients are now spending out-of-pocket money. They’re going to take a little bit more time asking the question “what is it going to cost me? What’s the value I’m going to get?”

More importantly, “If you’re going to try and draw my blood again, I might have to pay for it, so I might actually give you my lab result now, because I don’t want you to do it a second time.” Previously, what was it? You’d go to the one doctor, they’d draw your blood, you’d go to someone else, they’d do it again. You go from one dentist to another dentist, they do your x-rays. Not only do you get radiated twice, you get more radiation in your body, you pay twice. Now people say, “No, no, no. Wait, wait, wait. This is costing me money. I’m going to take my stuff with me.” So now patient engagement, in both cost quality in labs and medical information, is directly tied to economics; the day that happens, industry changes.

At the end of the day, money is not the only factor, but sometimes it’s a big factor in influencing what happens. Today consumers are going to ask the question, “Where am I going to get my service if the quality is the same?” How are they going to find lower cost standpoints? It’s going to change the industry.

Q. Yeah. Do you think there will be regulations of costs nationwide? Do you think we’ll see that in the future?

There won’t be a regulation of cost. It’ll be a visibility of cost, and the best cost providers will survive. That’s how it gets regulated in a capitalism economy, and that’s what’s going to happen. That’s how you and I buy cars today. That’s how you and I go decide what option that we can spend our money. We try and understand the safety, the value, the money, and then make a decision; and usually that means you better start competing in an open market. Healthcare has not been in that space. It will change next year. It will change the year after. It’s not going to turn back anymore. You know Medicare already published the data. More and more employers are asking for more and more data from their peers.

Q. That’s right. With all the future talk in mind, let’s talk a little bit about eClinicalWorks. I know you can’t give away any thing, but where’s the focus now for you guys in say the next five years?

I think we’ve got our vision always the same: improve healthcare by building a supply chain of consumers (which are patients) and providers (which are doctors and ancillary service providers like labs, diagnostic imaging centers, laboratories), and find a way for this to be a fully digital, cloud-based solution. I think in the next five years, the size of this cloud will increase. We’ll have more patients. I’d like to get to 100 million patients within five years using the technology. We are at about 14 million on one side and six, so I’ve got about 20 million today, so I’ve got a long way to go to get them in.

We do, on the other hand, have 200 million plus patients whose electronic health records are in eClinicalWorks’ EHR. I think we’ve got a good start to get there. That would be the focus: further improve quality of care by building technology that allows providers to understand what they should do (which will be population health) predictive modeling, and make the EHR more easy to use on iPads, so their doctors don’t have to worry about point and click. I think we’ll continue to innovate. It’s going to be a fun, fun, fun five years, but it’s going to be a roller coaster.

Q. Yeah. One last question about the population health: We just talked about why there was no incentive before, and now patients are really thinking about their own health, especially with high-deductible health plans. Do you think now, applied to the provider mindset, more providers are really thinking, “OK. How do we execute population health management effectively?” That the mindset has evolved within the last year or so?

Yes. The last year there has been a dramatic change. There is a definite interest. There is also a definite realization that managing a population of patients, not just for primary care, even. I was talking to a large orthopedics group, and they’re talking about how are they going to reduce the cost around hip replacement and still keep the same quality? I have Ob/Gyn’s asking the question, “How are we going to reduce the c-section rate?” because at the end of the day, that’s not going to work healthcare-wise to have un-moderated, uncontrolled, unverified c-sections. I think, yeah, absolutely. I hear it every day now.

This article was originally posted by Erica Garvin on July 28, 2014

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