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June 24, 2005

TECH: Conversation with Girish Kumar, eClinicalWorks

I wrote a brief editorial in THCB and also on FierceHealthcare last week, suggesting that the problem with IT in the US wasn't so much a lack of interoperability as it was a lack of use of IT in the clinical workspace by physicians in small practices. My editorial was in part inspired by a comment emailed onto me from Girish Kumar, who's President of eClinicalWorks--an EMR vendor aiming at that market. Given that I'm doing some work on the use of ePrescribing by doctors in that market anyway, I thought I'd imitate MrHISTalk and do a CEO interview to go down a layer or two about how that small practice segment of the market is playing out. So here's my take on my discussion with Girish.


eClincial Works is based in Westborough Mass , and it's a private company with no debt and no investors and no plans to go public -- working in a similar philosophy to Meditech just down the road. Currently it has around 150 employees with some $20-25m in software revenues on an annualized basis. They are doubling in size each year with 1500+ customers representing 3300 providers (meaning nurse practitioners and doctors). Their business is focused on the small end of the market, which they define as practices with 1-15 physicians, although they have started going into mid (15- 50) and large (50 +) practices. And a couple of even bigger practices have signed on recently, although that's not been their prime market.

What about the market in general?

Girish believes that EMR adoption in health care is a long term process -- and that realistically we are still 5-7 years away from peak adoption rates and some time after that from total penetration. He was (he says somewhat mis)-quoted last week as suggesting that government help was needed to get that market to take off. He does think that the conversation emanating from Washington is creating a catalyst which is helping physicians move towards automating their practices. But this is a numbers problem. While there are only a few thousand hospitals and big practices, there are over 150,000 small practices. Their EMR adoption is low in percentage terms but quite a few have EMRs which makes a large total number. Girish says that as eClinicalWorks continues to see more and more business every quarter, that tells him that the market is moving forward rather than backwards or sideways. But, and this is the key issue, the numbers of doctors needing to make that move are so large that unless the government puts in place bigger incentives the market won't go from 30% adoption to 80% without a catalyst any time soon.

Is there a distinct set of players for different practice size?

For practices with 50 + doctors there are a now a more or less dominant set of EMR vendors, such as NextGen, Epic, Allscripts & GE Centricity (Logician). When you go to the below 50 doctor market, it's coming down to 6-8 companies too, but not the same as the larger ones. For example, Epic doesn't sell into that market. There are many smaller vendors who used to be able to be much cheaper than the better known companies, but the challenge for those companies is that original price point of $15-20,000 per physician is now falling. So the difference between the small vendor and bigger, better-known players has come down. For example eClincalworks' EMR is $7500 a seat (you need to add $2500 more for the practice management module).

This is being accompanied by some level of market confidence in the vendors. Girish claims that others are telling him that eClinicalWorks is becoming a brand name for EMR. In addition the vast majority of doctors who buy their EMR product are also picking up the practice management application, and are starting to replace the Medical Managers of the world. As in many other parts of the health care IT arena, the value of the pre-integrated product can exceed the reason for keeping a legacy practice management system, and he expects to see that trend continue. Incidentally, some of his competitors, don't share that view--Allscripts for instance doesn't have a practice management module and integrates with those legacy systems. But clearly if physician organizations can recognize a distinct set of vendors who will be around for a while, then it will help the market.

So what should the government do?

In Girish's view government is recommending the standards for building the highway, (interoperability and RHIOs). There's no question that you need that for nodes (or in his analogy, cars) to be able to able to connect with each other. But we need to focus on the nodes, and we have to build the on-ramp and off-ramp to the highway. The government needs to incentivize both the infrastructure creation and incentivize the plug-in at the doctor's office. He's not critiquing building the highway but we must realize that we need the cars too.

What should that look like at the node level?

The government should come up with a subsidy either via Medicare or a pay for performance package directly related to IT adoption. Then the government should mandate that vendors implement interoperability standards at no additional cost -- customers shouldn't be burdened with the extra costs of interoperability. We need to build an incentive to vendors to do that and that incentive for vendors should be a growing market. In other words, create a market so that the vendors make more money but force them to make interoperability part of the products features. In one example Girish cited a vendor who wanted $60K to integrate inpatient and outpatient information together for single practice. That's not acceptable to him and the path to interoperability ought to be built into vendors' standard product roadmaps.

Having said that, there is only a small demand from doctors for seeing the inpatient chart in the outpatient environment, although that varies by specialty. For example, no dermatologist cares, but an ObGyn or cardiology practice might care. The big deal in terms of interoperability is access to lab results. However, overall adoption will be easier if physicians know that the products they buy are interoperable and that they are both able to get information from other systems and able to walk with their data if they don’t like the system they have.

So why should the government subsidize the EMR?

Putting aside the fact that the government subsidizes lots of parts of the health care system already, I pushed him a little on the idea of subsidies. After all if adopting technology gives the physician efficiency (and several vendors show that in their studies) and it's saving them money, why should there be an incentive from the taxpayer? Girish felt that the improvement in care EMRs would create would save Medicare and the government money in terms or reduced hospital admission, better drug compliance, etc -- so in his view it would be an investment. But he was happy enough with a proposal that any subsidy should be budget neutral overall for physicians, but that Medicare or the government would essentially be paying them to adopt the EMR while they were paying them less for other activities in their practice.

While I agree and I think that the P4P movement is pushing this way, I can imagine the AMA might not agree quite so readily! Still, I'm with Girish in believing that the adoption of EMR tools in small practices is the most crucial aspect of IT in health care, and it’s good to hear that there is some activity in that arena. And that at least one vendor is talking a good game about how that market can be grown at benefit to all of us.

June 24, 2005 in Technology | Permalink


I'm wondering if costs could be brought down by getting doctors out of the Cost of Technology Ownership business. Maybe what's really needed are Application Service Providers. Maybe the same ASPs could also run a data warehouse to protect the patient information of thousands of small physician offices. Besides encryption and a VPN, I'm not sure what other protective measures would need to be taken. However, I'm sure physicians would prefer to just point and click to their web app, and that's the limit of the IT investment they have to make.

The problem with the efficiency of consolidation is that the vendor might get such a market advantage that he/she might dictate the prices or squeeze "incentives" out of the government. :-(

Also, I'd rather see consumers incentivized than businesses.

Posted by: gadfly | Jun 24, 2005 9:29:55 AM

Thanks this is really helpful.

As a non-IT person who doesn't understand the technology, here's what I'd love to see in a decade or so. I show up at the emergency room, and they can see my records. I'd like to see different levels of access. So, all the details of my therapist's notes might require a phone call to the therapist for extra approval.

But otherwise, I'd like to have more control over the process. If I want to switch doctors, I shouldn't have to go through any hassle getting my records transferred.

Posted by: Abby | Jun 24, 2005 9:49:46 AM

Thanks this is really helpful.

As a non-IT person who doesn't understand the technology, here's what I'd love to see in a decade or so. I show up at the emergency room, and they can see my records. I'd like to see different levels of access. So, all the details of my therapist's notes might require a phone call to the therapist for extra approval.

But otherwise, I'd like to have more control over the process. If I want to switch doctors, I shouldn't have to go through any hassle getting my records transferred.

Posted by: Abby | Jun 24, 2005 9:50:19 AM

Sorry about the accidental doubleposting. Please feel FREE to delete the extra one. And when you've done that, you might as well give this one the axe too.

Posted by: Abby | Jun 24, 2005 11:13:53 AM

You got eCW's price wrong. Up-front it's $10,000 for the first provider (including the billing component), $5,000 for additional providers--NOT 'seats'. You can have as many users as you want.

eCW's successful innovation in the marketplace was a SUBSCRIPTION option, $400 a month per provider, as I recall, which like ASP eliminates much of the up-front costs. The product is also available as an ASP for another $100/provider.

There are both government and industry initiatives for inter-system exchange of core patient clinical and demographic data, so what Abby is looking for is not far down the road. A 'meta' database may be what's really necessary, but there are large impediments to that--mainly concerns about privacy and Big Brother (rather overblown, in my view).

/Mr Lynn

Posted by: MrLynn | Jul 19, 2005 4:37:09 PM

There are multiple issues regarding the implementation of Physicians and EMR. I have experienced this first hand in many ways.. First as a consultant to private practices in their Hardware/Software implementations and secondly as a physician (graduating from MD school this month).

First, The knowledge gap between physicans no matter what size of practice as technocrats compared to say consultants or corporate america is HUGE. Most often times the learning curve for physicians to incorporate EMR into a practice is very very high. And the one thing that Physicians don't have cheaply is Time which = money Especially for Primary Care Physicians. This has to change.. The Void between Products made by engineers, and what Physicians need is very large... Additionally the ability for a User (Physician) to customize and streamline the use of the product to the way that they think, and operate as a physician easily is not there. Most softwares require the outside vendor to set up these customized options, or require months of planning prior to implementation to try and get these processes in place. Currently in primary care, due to the increase in overhead(staff/IT/malpractice), decrease in reimbursements.. and Now even increase in education debt.. efficiency is everything.. Getting a physician to abandon his paper process that he has honed his/her skills on from Med School through residency to something completely foreign is a huge barrier to entry. Additionally keep in mind that IT costs are very new to physician offices 10 years at the most... so when you say plop down 50-150K in IT overhead to go paperless.. thats a tough pill to swallow.. when Microsoft Office is only 500 dollars per a computer.50-150K is what I consider enterprise costs.. its what you would expect a multimillion dollar company to pay on their IT Software implementation (I have seen SAP and supply chain software implementations cost less for companies with revenues much larger than a small primary care office)

Secondly, I would consider Training a very large factor. Although the U.S. boasts arguably the most advanced healthcare treatments in the world, our operations and internal processes are horrid. This "loophole" is what allows for the inefficiences of medicare, and the ablity for insurance companies to gouge on reimbursement rates. Most Physicians train at large community or state run hospitals, (the VA aside) with deplorable IT systems and softwares.. From M.D.'s training standpoint.. the main focus of training is on how to treat patients.. see as many disease states as possible, and do as many procedures as possible. Organize and present patient information (usually on paper) as quickly and efficiently as possible. Most doctors are not even taught how to properly bill. They don't give us classes in m.d. school or residency on medical economics, or Coding. Many physicians that I know personally found out that they had been improperly billing for years before they found out how much money they lost.

In a nutshell the IT issue is complex as we all know. And it really is the only way that alot of these loopholes and inefficiencies in the current provider market will be changed. But at the core root of the problem the training of most physicians is still based on training methods that are 50 or so years old. And the technology training for physicians is not inplace.

Lastly, I want to point out that the majority of softwares for physicians are very much proprietary adding to their already inflated costs. The use of open source technology is limited in this market (as everywhere)so having your core DB run on Oracle MS SQL etc already aids to the complexity of the software before a single line of code is written. The use of Linux, XML, MySQL, Tomcat, Apache etc are ways to significantly reduce licensing costs and development costs as well. Not to mention to allow for a much simpler implementation and support, if all done correctly. I never met an office manager that could really work on a Win2k3 server or deal with MySQL issues. Keep in mind these guys may have 50K to spend on an implementation, but they don't necessarily have an IT department, and support costs. It may only cost 10K for a provider on eclinicalworks, but I doubt that that covers the support contracts etc. You have to allow for the system to be operated and basic trouble shooting and customization to be done internally by the practice with minimal training.

Well here are my two cents...


Posted by: ADS M.D. | Jun 20, 2006 8:13:38 AM

I find all of this very interesting. I have been in the medical field now for 26years. I have worked in many positions in that time starting out clinical turned sales and marketing. Working at a local level and then with much larger firms such as GE Healthcare.

In each of the positions I have held, teaching medical personnel has always been a huge part of my job. I am now looking to move into the EMR training role. I find this whole concept invigorating and challenging.
e-Clinical is one of the EMR vendors I am looking at for my new Career home. Mainly because I am very customer focused and by far, all of the information I have read so far has brought me to them as they too believe in total customer satisfaction!!
I feel that ADS M.D. has sold himself short if you will in that I have always found physicians to be highly intelligent. Training physicians has always been rewarding to me. They tend to challenge me with their insight and encourge me to see things in a different perspective. Because of that, I have looked at many ways to educate folks in order that EVERYONE understand before I leave. Each person will need their own way of learning. I have come to understand that, so customized training is what I provide. That is where I excel and can help a EMR vendor excel!!
I agree with ADS M.D. in that we most definatley need to focus on EMR training. My way of doing this would be of course not a cookie cutter way at all, but more of a customized solution. Each customer, each individual will need their own degree of EMR training. I know I would be able to provide such Total Quality Customer Care, because that has always been my philosophy.
I hope that one day, I will be alble to provide this service to Dr- ADS M.D.

Let me show you, I am up for the challenge!!


Posted by: PJH | Oct 15, 2006 5:13:40 PM

just one comment-- please over look my misspelling of able-- I was typing too fast!!

Thank you.

Posted by: PJH | Oct 15, 2006 5:19:11 PM

I have no ties with the medical field with the exception of providing project management and IT support for a doctor who implemented eClinicalWorks in his office. He is now paper-less (i.e., fewer sheets of paper, my friends; I doubt we will ever remove paper completely from the equation) and more efficient.

What I have found is that most small practices do not have reliable or permanent IT support. In fact, some use very little technology in the day-to-day practice. There are considerations when implementing a product similar to eClinicalWorks; you will need a machine capable of handling all the eClinicalWorks software and documents that are generated. This computer is required by eClinicalWorks to perform no other operations other than running their software and serving files. The office will need to meet specific requirements for Internet access. Most workstations need to be replaced or upgraded (software and hardware). An appropriate network must be properly installed. A secure firewall should be installed, as well as VPN access (would allow a doctor to securely access eClinicalWorks at home as well as documents). There are many other considerations, and with the privacy concerns it is highly recommended to use a professional IT agency.

We are designing a service for practices in the Greenville, South Carolina area that allows the doctor to focus on what he does best, while we take care of the project management with eClinicalWorks, determining hardware needs, installation and implementation of eClinicalWorks, and IT support/training for the new equipment. We can service practices in other states, but we hope to have partners who can provide IT support by 2010.

It's interesting from my point of view that EMR/EHR software is being pushed by federal and state governments, but there seem to be relatively few doctors and staff who are experienced in the IT field, much less able to implement such a complex software/hardware integration. In my 12 years of IT and software development, the government might as well be telling me to begin to seeing patients and prescribing medication... something I know nothing about.


Posted by: Benjamin Menking | Oct 19, 2006 8:35:35 PM

Dear BDM:

You wrote....

"What I have found is that most small practices do not have reliable or permanent IT support."

I started Medical Practice Technologies in 2002 just for this very reason. To provide honest and competent IT services and ongoing support to private medical practices nationwide. So you can use the system, see patients, have a life, and not worry about it's reliability and maintenance.

Qualified and competent IT support specialists are hard to find. Ones that understand and specialize in the medical field are even more difficult to locate.

Putting an EMR system together is not just running to Best Buy and picking up some tablet PCs. This is your business and your lively-hood. Most practices we work with are 5 physicians or less and do not have the need for a full time in-house IT specialist.

I wish there were more companies like ours out there, but unfortunately most practices end up doing the best they can on their own and many times put their data at great risk.

Best Regards and best of luck to everyone working toward implementing an EMR.

C.A. Nix III
Medical Practice Technologies

Posted by: C.A. Nix III | Nov 27, 2006 6:37:51 PM


It was very interesting reading about everyone's point of view.

My take on individual issues that surround EMR/EHR
1. Standardization
It's great to see that communities are getting together to standardize patient data via RHIO and Government mandates. Hopefully there are some direct incentives along the way for all. JCAHO is one very good example.
2. HIS Solution
It's good to do your research around for HIS systems including which modules are appropriate for your organization. I recommend this is a phased approach as well. Support/training costs which really cannot be ignored or completely eliminated due to rapid advancements in technology (my humble opinion) but can be controlled moderately by looking for solutions that are "quick and easy" to implement AND the client interface is very user-friendly. I really stress on the user friendliness - basically in my opinion an interface is considered "user-friendly" if a non-technical user can use all of the basic and important features in any application without one's help. Browser clients as opposed to native / to-be-installed clients are great examples of good user interface (everyone know what a browser is these days)
3. Interoperability
It will be great to see all HIS vendors provide interfaces via API's and allow the organization to decide what/how/when data needs to be interchanged. Once such a mechanism is created, other rich features (for a true EMR environment) start to surface such as "data accessibility", "portability", etc. The Internet is one of the greatest mechanisms available to all for data interchange. This leads to the most important topic for all of us "Data Security and Privacy"
4. Security and Privacy
I think the various policies that are being enforced within HIPAA will take care of the privacy and security and all of us (from a Technologist or a Service Provider to a patient) should strive, constantly, to add and modify policies as we discover loopholes.

They way I look at it “In an emergency I would absolutely want my health information accessible by any of the attending service providers whereas all other cases I would at the very minimum need to know about my data and some cases even control it if possible.”

I think this is a unanimous point of view!

Suresh Kumar (Technologist)

Posted by: Suresh Kumar | Jan 3, 2007 4:23:27 AM


How do I contact you? I am working with a medical management group, trying to get physicians comfortable with an EMR program we will be rolling out soon. I need some advice,

Posted by: Ken Heinrich | Feb 20, 2007 11:51:25 AM

u can email e clinical works or call them.....

Phone: (508) 475-0450

Phone: (508) 836-2700
Fax: (508) 836-4466

hope this helps .......

Posted by: nikita | Apr 3, 2007 3:00:59 AM

My company has used eClinicalWorks for 2 years. The comments above (especially by ADS M.D.) regarding the unforseen complexity and expense of electronic billing and paperless offices are well put. Software packages like eClinicalWorks market themselves as perveyors of simplicity and also easier access to practice information. While the latter is certainly true, use of eClinicalWorks has increased both the expense and complexity of billing and IT within our company.

As noted above, such increases are likely by-products (requirements) of introducing most modern practice management software, regardless of brand. I will go into a bit of detail here. In our case, use of eClinicalWorks initially required investment in a small business server, VPN (multiple locations), and more robust networking equipment. After two years, largely due to our use of eClinicalWorks, we added two administrative staff because eClinicalWorks heavily structures certain workflow and not in the most efficient way (complicated EMR interface and time consuming EOB posting process) and lacks other capablilities entirely (track incoming referrals, track patient progress in our care, inventory tracking for DME we sell, data export to accounting software). Additional expenses emerged as we recently signed a $10k/year maintanance contract with a local IT company (we lack an IT dept.) and just installed a new server which cost $12k. So while it is true that eClinicalWorks has low monthly costs, other costs inevitably arise and should be factored into any switch to practice management software. Practice administrators should also realize that these types of software may not work entirely as promised and may have glitches causing work-interruptions and frustration among staff. These issues have become part of the unforseen costs also.

While eClinicalWorks has not turned out to be nearly as cheap as expected, products from the heavy hitters like Cerner, NextGen, and Centricity all require 50-100K initial investments with yearly licensing and service fees.

Still, my experience with practice management software taught that these technologies do not increase efficiencies for providers. Seeking efficiencies for itself, the federal government requirement of electronic billing shifted that inefficiency squarely on providers.

Many industries have leveraged computer technology to create efficiencies and consumer choice by automating processes formerly performed by people. such efficiencies required data exchange standards. While the prospect of payors, the medical industry and government payors accepting standards for data exchange is exciting, that senario seemed a distant dream. This meant that providers carried the burden that universal data exchange promises to alleviate. Automated Prior authorizations, patient demographics input, posting of EOB's, medical records exchange would have not materialized for most independent practices. Until the promise of technology is realized in the medical industry, the cost of doing business for independent providers will continue to be disproportionate to larger providers.

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