Canvas

So today we’re chatting about Canvas and how it’s used at your company. Before we jump into that, could you give a brief overview of the company and your role there?

We’re a risk-bearing medical group that focuses on providing value-based care to patients with chronic health conditions. Currently, our main partnership is with a health plan. When a patient enrolls in this health plan and they have some stage of chronic kidney disease, about 95% of these patients are referred to us. We then receive a percentage of the premium for each patient and become responsible for covering all their healthcare costs.

To ensure comprehensive care, we have a dedicated team consisting of a navigator, a social worker, and an advanced practice practitioner (either a nurse practitioner or a physician assistant). This team conducts an initial visit with the patient and assists with referrals, obtaining supplemental benefits, and managing transitions for those who have hospitalizations. We also visit patients during treatment if needed. Our goal is to establish strong relationships with our patients and ensure they receive the necessary care. In return, if we can reduce the total cost of care while improving quality of care, we’ll do well financially.

How long have you been using Canvas?

About six months.

What was the need that drove you to look for Canvas?

We knew we needed an EMR, as we were running a medical group and handling patient care and claims. When I joined, the company had already chosen eClinicalWorks as our EMR. However, after about nine months of struggling to implement it in our model, we determined it was not suitable for our needs. We believed that users would dislike it, and the implementation was going poorly. In the process of researching new vendors, I came across Canvas.

What were your primary requirements in looking for an EMR?

We knew we wanted to have access to all the data. We considered athenahealth, but unfortunately, they didn’t provide the necessary access. It was quite difficult to obtain our data from them, which was a dealbreaker for us. On the other hand, eClinicalWorks offered a daily database dump, but it was slow and came with several complications that we weren’t happy about. In contrast, Canvas offered a real-time replica of our production database, which aligned much better with our data requirements.

Another big piece for me was the ability to import and export data. eClinicalWorks had limited options and was rigid. They only allowed writing a text HL7 file to an SFTP server without any error checking, which was inadequate. We wanted to have an ecosystem of tools, including a CRM for engagement, an educational tool, and our own portal. However, eClinicalWorks couldn’t support any of that. We needed a tool that would seamlessly integrate as part of our ecosystem.

And eClinicalWorks had an interface that was not easy or pleasant to use. Canvas provided a more intuitive way of charting. When I spoke with people who were using Canvas regarding what they were satisfied with and what their pain points were, overall, while there were some drawbacks, they all had positive things to say and liked using Canvas. This was also a positive indicator for the end-user experience.

Were there any other vendors that you compared against Canvas?

The team originally looked at a company called AaNeel, which was being used by a sister company, and it was in its early stages, possibly even earlier than Canvas. At that time, AaNeel was not yet certified for meaningful use, although they later obtained the certification. During the Canvas implementation, we had a few meetings with the CEO of AaNeel, but I personally never felt convinced that the company could meet our needs.

When comparing Canvas and eClinicalWorks, we dove deeply. eClinicalWorks was probably more advanced when it came to claims processing, and one of our clinical documentation integrity specialists felt that Canvas was a step back from eClinicalWorks, although she also agreed we should move to Canvas, despite it making her function more challenging. I think everyone else saw it as an upgrade. Also, I want to mention that the implementation team from eClinicalWorks was the worst I have ever worked with, regardless of whether they were in healthcare or not. They often couldn’t even demonstrate their own product, and their professionalism and helpfulness were severely lacking. So we were ready to switch.

Canvas offers protocols that allow you to write code specific to your instance. As someone with a computer science background, this was really interesting to me. It meant that we could actually develop our own tools and have them integrated within the EMR while retaining ownership of the code. With eClinicalWorks, anything we added to the EMR would become their intellectual property. This was a major concern for us, but unfortunately, we couldn’t negotiate it out of the contract. Canvas has an open platform, allowing us to build our own ecosystem, whereas eClinicalWorks wants to be the exclusive provider for everything and only allow clients to use their approved plugins.

Did you do an in-depth evaluation of athenahealth?

I wasn’t with the company at the time, but from what I heard, they didn’t delve too deeply into athena. The problem was that extracting data was not as simple as inputting it, which was a dealbreaker for us, especially in value-based care. We needed to conduct extensive business intelligence and data analysis. In my experience, most modern companies I’ve worked with use something like a Snowflake instance, where all the data is stored. This approach seems to be the norm in the modern world. In contrast, eClinicalWorks felt outdated and cumbersome.

Do you know how the pricing compared?

eClinicalWorks had a fixed price structure where you paid a certain amount based on the number of instances you had, with an additional per-user fee on top. On the other hand, Canvas had much lower fixed fees, although the initial cost was a bit higher. However, we were able to negotiate some pricing that balanced things out. The financial team preferred Canvas because they believed it had a better potential for growth. So even though we were deciding at the last minute, it was actually an easy decision to make.

How did you find the sales process with Canvas?

We were in the process of implementing a different EMR, so we had a long list of questions. I personally went to each stakeholder and had them write their questions in a designated section of a document. We then passed that document on to Canvas and went through each point together. In the end, I asked our stakeholders whether we should stick with ECW or switch to Canvas, and there was near-universal agreement to switch to Canvas.

Canvas’s sales team was incredibly supportive throughout the process. They were very consultative and took the time to answer our questions and provide demos. They really knew their stuff. One major selling point for us was the responsiveness of their team. With eClinicalWorks, it often took a week to get someone on the phone, and even then, the demos didn’t address our questions, leaving us back at square one. It’s amazing how little progress we made in nine months. With Canvas, it was clear that we would be able to work much more efficiently and swiftly.

How was the onboarding and setup?

The onboarding and setup processes were quite similar to our sales experience. We decided to invest in a dedicated implementation manager and paid extra for their services. This manager was extremely helpful in answering all our questions and ensuring that our instance was tailored to our specific use case. Although it was fairly costly within the first year, it was definitely worth it. We plan to gradually decrease our reliance on this manager, as we now have sufficient Canvas expertise within our own company. We’re ready to handle things independently moving forward.

What are your use cases for Canvas?

Mostly standard use cases. Someone goes to a patient’s home for an initial visit. They use a Microsoft Surface with Canvas in a browser. They can either type their findings immediately or take notes and transcribe them later. Typically, they sit there and type during the initial visit. We also do chart reviews ahead of time. A specialist looks at historical charts and the HIE data and preloads a chart for the review.

Another thing we do in Canvas is transitions work. When we receive an ADT message that a patient has gone to the hospital, the team meets to discuss the case. We have a physician on staff who presents the findings, and the team assigns tasks using the tasking engine that’s built into Canvas.

We also submit claims and track them in Canvas. We make sure that all the necessary diagnoses are in place from a managed care perspective. A lot of this happens in Canvas, though some happens outside of Canvas as well. We’re connected to Claim.MD, which is our clearinghouse, so claims get submitted to our payor partner after each visit.

Scheduling is entirely done in Canvas. Providers have their schedules built into the system. We load patient information and contact them to schedule appointments. Canvas integrates with telehealth through Doxy.me for video appointments. Canvas also sends out reminders and has a messaging system for follow-ups.

Currently, our team uses the tasking feature in a somewhat unstructured way. We’re looking to establish a more systematic approach to it. The tasking engine in Canvas is very flexible and allows for various configurations.

We’re also connected to Zus, who is Canvas’s partner for HIE access. We can access the patient’s data from the HIE, including their conditions and medications, which can be brought directly into the EMR.

We make good use of protocols as well. For example, we require HRAs (Health Risk Assessments) for all patients in a SNP (Special Needs Plan). We have a protocol that generates a list to keep track of patients who still need to complete the HRA. We use similar methods for initial visits, follow-up visits, and risk stratification. It makes it easy to see which risk tier a patient falls into.

We also heavily rely on Canvas’s FHIR API. We receive a list of attributed patients from our payor client, process it, and then sync it with Canvas, our CRM, phone system, and other tools. So we make extensive use of their API as well.

What are Canvas’s strengths and weaknesses?

The concept of narrative charting is solid. The data is organized and easily trackable. The protocols, although a little glitchy in some areas, are being migrated to a new framework that will enhance their capabilities, which is an exciting improvement. Our revenue cycle person still has some reservations about how everything fits together, but there are external tools available that integrate well. From our team’s perspective, revenue cycle management is a slight weakness.

Additionally, our team likes a high degree of user interface sophistication. They like the ability to analyze patient populations and view different registries with more flexibility. Currently, protocols offer some of this functionality, but not to the extent they desire. They also want the capability to sort by any column. We have communicated these concerns to the developers, and they are actively working on addressing them. Like any software, there are always feature requests, but overall, we are quite satisfied.

Has the platform generally been stable and bug-free?

We’ve encountered a few bugs, but that’s to be expected at the stage they’re at. We’ve also come across some issues where certain features didn’t function as intended. However, there has been continuous effort put into improving the performance over the past year. Occasionally, we’ve experienced slowness with Canvas, but those problems have been eventually addressed. Overall, I would say it hasn’t been a barrier.

How would you characterize the experience of working with their APIs?

Good. It’s been really good. The documentation shows careful attention to detail and accuracy. It’s organized logically, and it looks good. You can also run test data on it. Out of the various APIs we’ve dealt with, I must say this one stands out as the best by a significant margin.

How was the documentation and developer experience?

They’re very helpful in terms of providing assistance and are willing to help you reset your development instance if you’ve made a mess of it. However, they still have some improvements to make. Compared to the average performance of other EHRs, the’re two standard deviations to the right. But when evaluated against the broader SaaS landscape, they still have some areas where they can enhance their offerings. For example, I would like to be able to clone my production instance while ensuring that the data is anonymized, allowing me to conduct more effective testing. They are currently working on implementing features like this, so I believe they are on the path to eventually become a top-notch SaaS tool. However, they haven’t quite reached that point yet.

What integrations are you using with Canvas, and how have you found the experience of setting up those integrations and using them?

The only direct integration with Canvas is Zus. Over the past few months, it has been generally good. Zus is even earlier stage than Canvas, so there were some challenges in getting the two systems to communicate. However, we managed to make them work together, and now the native experience of seeing HIE data go right into the EMR is exactly what our team wanted. Even with eClinicalWorks, we couldn’t achieve this. So everyone is really happy with the outcome.

As for the other integrations, we’ve done them ourselves within the EMR. You can use the FHIR API and protocols to make callbacks to different systems, though it’s a bit sophisticated. I don’t think Canvas has much of a marketplace for integrations. Their approach is more like, you buy what you want and then you handle the integration yourself. That’s exactly how we prefer to do it. We had a marketplace of integrations with eClinicalWorks, but it was not good at all.

How has the support been with Canvas?

A-plus. The great experience we had during the sales process has truly carried over. Our account representative knows Canvas better than any of our other points of contact knew their product. It’s not even comparable. And that has really made a significant impact. I think many companies don’t invest enough in this area, but Canvas has been outstanding.

Do you feel like you made the right decision with Canvas?

Yes. Once we made the decision, we never looked back or reconsidered. Everyone has been fully on board with it, and everything has been going really well. It’s been all arrows pointing up.

As you think about the product today, what would you point to as areas of growth for the product?

Their strategy seems to be moving toward a platform approach, where they want to focus less on building features and more on providing users with the tools to build their own features. I think this is a great idea, especially as healthcare becomes more advanced. You either have to specialize in a specific area and build features for that niche, or you end up with a complex system with numerous settings that can be overwhelming over time. So I believe their strategy makes a lot of sense, assuming the market continues in the direction it’s currently moving in.

Canvas is like the Salesforce of EMRs, where it has enough centralization for everyone to enjoy using it, but it also offers enough flexibility to use it for different purposes. It makes sense.

However, they still have a lot of sophistication to develop. They need a community of developers who can collaborate effectively. I suggested to them that since we already have an integrated phone system, and everyone needs a phone system, maybe they should integrate that directly. Perhaps some people could also build and share these integrated tools. I worry that if their software toolkit requires five developers working for a whole year to use it, it may not be very viable. So they have a strategic tightrope to walk regarding building a platform without getting overwhelmed by too many features. They also need to validate how good the apps are that are available. Right now, our company and Canvas are moving in the same direction, which makes me very happy. I just hope that many people will join us on this journey.

What advice would you have for other organizations that are going through the decision-making process on purchasing a product like Canvas?

Having a software person is really helpful, especially in healthcare where a lot of IT people are just used to writing contracts with vendors and calling it a day. If you don’t understand how the technology works, using Canvas might be a bit of a struggle. But since I worked with Python and Django 10 years ago, which is the stack Canvas is built on, I had no trouble understanding it. I’ve built my own Django apps, so it made sense to me.

The hardest thing about purchasing an EMR system is that it’s difficult to get rid of a failed system once you’ve invested in it. You can’t just try it out a little and see how it goes; you have to fully commit and hope for the best. That’s why getting references is crucial when selecting an EMR. With other vendors, we usually go for month-to-month contracts and do a proof of concept before signing a long-term agreement. This way, we can make sure the tool actually works as they claim, because sometimes they say it’s easy but it turns out to be the wrong choice. We’ve already had to replace our phone system because of a similar situation.

I do think that checking references is important. If you can look at someone else’s instance of the software and imagine yourself using it, that’s the best assurance you can get before making the decision. With Canvas, however, I would say you need to have a little more technical expertise to build with it, compared to other tools.