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 roles there?

We do exclusively virtual care with remote monitoring for our patients. We’re focused on cardio-metabolic health, so we started off by focusing on patients with hypertension. We’ve now moved into weight management and then lipid and early diabetes management. So that’s kind of the core of the cardiometabolic health perspective.

I’m the Director of Clinical Operations; I’m a nurse by background. We’re part of the early team that started the company, so we kind of do a bunch of different things, but essentially, my goal is to improve the patient and provider experience. I get firsthand experience of that by working directly with patients as well as by being a kind of hybrid employee within our MSO and PC structures.

_My role is pretty similar, but I’m slanted a little more towards patient care. Ultimately, I deliver patient care, identify ways to improve our processes and support our providers, and run the clinic. _

At a high level, what drove the need for a product like Canvas in the first place?

There’s no way we could do virtual primary care without an EMR, so that was a pretty basic need for us.

One of the things that we were interested in was something that met both our clinical and technical user needs. We knew, as a small company, we probably wouldn’t have much influence on the larger EHRs out there.

Was there anything in particular that you were looking for from a clinical and technical requirements perspective?

I don’t know the specific requirements that the team actually had drafted as they did the demos, but I imagine they were focused on the “table stakes” EHR capabilities – the basic functionalities and features that any EHR system would have to possess. A key consideration of course was that our patient base would be seen with both synchronous and asynchronous care, so that was an important aspect. We needed to enable remote monitoring and make sure that we had a good starting point from a patient portal perspective. We’ve now moved away from Canvas’ patient portal, but it was sufficient to get us through the initial launch of the clinic so that we could focus on other priorities. We also needed quick implementation.

Which competitors did you look at, and how did they stack up against Canvas?

We weren’t part of the initial demos, but we can shed some light on that. Elation and Athena were the two other vendors that the team looked at. And then we actually looked at them again about three months after we launched Canvas because we had a moment where we suddenly weren’t sure that this was going to work for the clinical team. In reality, it was more that we needed some ongoing services, support, and advanced training. As a result, we have a managed services agreement in place with Canvas that has really allowed us to move through that hype–hope curve of EHRs.

One of the things that we’ve shared with Canvas was that it’s essential to have people in place after you go live, because this is not your standard SaaS – you’re working with clinicians and end users who are using this day to day. You have to have someone there to assist them when the basic training they’ve been provided with doesn’t suffice.

So the driver to reassess your use of Canvas was because clinicians were having difficulty getting up to speed and using the product?

Yeah, and to be clear, we kept the clinic running and we kept using Canvas, but internally, we did set up vendor demos with Athena and Elation. We thought that, if we’re really struggling to use this clinically, we’d be better off making a switch early on and transitioning that patient panel early on, rather than continuing to try to work through the challenges and then having a larger pile of work to do in the future.

Are you still using the managed services solution?

We’re still paying and using it in some way. I would say we’re definitely using it less than we did when we initially had that set up about a year ago, which is a good indicator. We talked to our account manager – who is one of our favorite people at Canvas, ever – and when we got to the point where we had fewer agenda topics for our account manager and we could start canceling our meetings every other week, we felt that was a good sign that we’d made it through that valley of despair we’d experienced while we were going through the learning process.

Just to go back to the competitive set again, can you summarize what stood out about Canvas relative to Elation and Athena?

When we were involved in the re-evaluation stage, after we’d implemented Canvas, I think it was more the case that nothing about the other products stood out sufficiently to make them rise above Canvas. We realized that each product was going to have a shortcoming one way or another and that we were just going to have to work around those shortcomings regardless of which product we were using. We also felt that, with Canvas, we had more opportunities to customize it and make it work the way we wanted it to.

Do you have a sense of how the pricing models compared across the board?

I don’t think pricing was actually a significant driver of the decision. I know that we were willing to make a change if it was required and if it was justified by the pain points, but we realized that some of the pain points that we were experiencing were really trade-offs. I think what we understood during that set of demos was that EHRs are generally not great tools and are generally cumbersome for clinicians. What was important to us was making sure that we had a vendor that we could partner with as we grew as a company, as we scaled, and as we iterated certain things, and that our technical team felt like they had the capacity and ability to make changes. I would also say that we didn’t set ourselves up for success with Canvas. Ideally, if you do a Canvas implementation, you’d have technical resources assigned early on to identify and do training and learn the system as a technical user. But we’re a small company, so we had one engineer at the time. We assigned the set-up to our engineer, but whenever we went to Canvas with requests, they just indicated that we could set this up through our API, which was frustrating.

You mentioned that the ability to customize was important to you. Can you give us any high-level indication of the kinds of customizations you were looking for from a solution?

Maybe integrating is a better word – we wanted to be able to work with the RPM that we receive and with our provider portal. We discover new needs as we go along. At one point we needed to pull RPM data into the chart. So we needed to have the flexibility to be able to do things like pull data in and out of the system.

Long term, I think it’s possible that we end up with a headless EHR concept, where we’re documenting within our own admin portal and that information is being pushed to and driven by some of the Canvas workflows and tooling.

Do you have any comments to share about the onboarding process and experience?

The onboarding was pretty much like an assignment of videos to watch without much context. And part of that was attributable to the fact that we didn’t have any patients when we started with Canvas, so we weren’t able to apply any of the things that we were learning. But the videos were also very short and tightly focused on specific commands, so it was difficult to tie it all together and to understand how everything was going to come together to create this EMR experience for us.

Yeah, I felt like the cart was put before the horse for us, where we wanted workflow-based training, but we didn’t have workflows. Basically, we wanted a community library or forum where we could learn from other Canvas users, and that just wasn’t accessible to us.

We’re still a small team, but we’re currently onboarding our first nurse practitioner. She’s familiar with Canvas, which is fantastic. As other providers join who are used to tabular EHR systems, I feel like we’ll need to have better training around the shift in thinking that happens clinically when you’re in Canvas versus a tabular system. Canvas uses more narrative-style documentation, which affects how you search for and find information, but most clinicians are used to all of the separate tabs that you would see in a traditional EHR like Athena.

I’m assuming that the managed services portion of your engagement would have played a role in this; can you add any more detail there?

Well, we had the basics to get us going, but we didn’t have workflow-based training and we didn’t have workflows. So once we started to actually establish our workflows and open our clinic, we found that the short training videos didn’t suffice to allow us to become power users – or even just somewhat proficient users. So again, I think that EHRs require a little bit of hand-holding of the clinicians after the system goes live – once the clinicians are actually using it in patient care – and not just in the form of these perfect training exercises or videos.

We don’t have a training environment for Canvas. I think we just had one test patient and completed some practice documentation on that. Something I’d love to see in future is a dedicated training environment with some mocked-up patients that we can refresh on a regular schedule.

It sounds like you’re using Canvas as a core EHR. Can you add a little more detail on how exactly Canvas fits into your clinical workflow?

We’re using it to record chart notes and to store lab information. We also use it to order prescriptions and to order labs when available. We’re not using it for scheduling. Virtual visits are possible in Canvas, but we’re not using that.

We have our own patient portal and provider messaging.

Right; we’re not using messaging. We don’t use the Zoom integration either. We’re doing some work with their protocols now. We’re not using any of the population health functionality.

We do our own reporting, and we have our own data warehouse.

We do use it for billing; we’re capturing insurance information and performing billing tasks through Canvas, and we’re invoicing patients via Canvas.

We use Zus for external patient records and we have created some light integrations between Zus and Canvas, with medications coming through for patients in Canvas.

How did you figure out which set of features to use in Canvas versus what you’re managing externally?

I think that, for all the features we’re not using, it’s because there was some limitation in using the Canvas version of it. For instance, we needed to use Acuity for self-service patient scheduling.

Then there’s the Zoom integration. We had one link for every appointment, so we wanted individual meeting rooms for each appointment. As for messaging, Canvas only allowed for single-thread messaging, which was complicated for us to manage. There was very little formatting, which has evolved over time. I think the Canvas messaging tool has evolved since we used it, but at the time there were limitations that made us look elsewhere.

As a small, early team, we were trying to identify the key priorities and then determine which of those could be handled by Canvas. We also wanted a plan for more interim or long-term solutions. During that process we did force Canvas to have quarterly business reviews with us, but those have stopped. I was a little surprised: I know they’re also a startup, but I was really hoping to have more of a view into their roadmap and some discussions. I know that we, as a virtual care provider, are part of one of their strategic customer groups, but I feel like we haven’t been able to provide that much feedback or input aside from the specific conversations that we have with our account manager, which he then takes back to his product team. We did try, for example, to have a quarterly business review where they would tell us what their plans were for scheduling so we could assess whether that met our needs or whether we needed to look elsewhere. So we did try to assess whether this was sufficient for our needs at each specific stage so we could look at alternatives if needed. As a general strategy, our organization has these tech-enabled workflows with a tech stack that our team helps to eventually streamline through our clinical workflows.

Based on your current usage of Canvas, are there any areas for growth or any particular weaknesses that you can identify?

We constantly talk to them about their invoicing. That’s an area that we often give feedback on.

That’s our invoicing to patients for bill payment purposes.

It doesn’t seem to work for patients most of the time. I know that this is not a priority for Canvas – they’ve mentioned that most of their customers are using a third party for invoicing. So it’s just unfortunate that we are using them for invoicing – it’s just not a smooth process for our patients. Patients receive a link that they should use to access their invoice or their bill, and many patients have a hard time. They report that the link doesn’t work or is ineffective and they’re not able to access their bills. Some of the integrations are also problematic – particularly the lab ordering.

As for other things, we’re really limited in terms of reporting. For example, there’s no self-service reporting, which is challenging. We’re also heavily reliant on tasking in Canvas – the tasking function is great because it’s flexible and it’s a helpful workflow tool, but it’s pretty basic right now. For example, a task can only appear as open – either it needs to be done or it’s complete. We can’t say that something’s in progress. We can’t do quick shortcuts for dates. We can’t say T + three months for ordering repeat labs for a patient. We actually have to go into a calendar selector to do that. So I would say while tasking is definitely something that we use heavily, and according to Canvas, other customers use heavily as well, it doesn’t seem like they’ve spent much time on improving tasking. There’s also no decision support at all for any aspect of our workflows. I would say the other thing that we could probably highlight is the medication history – there’s none.

_The other thing that I wanted to highlight that’s missing is the ability to communicate amongst providers within Canvas. There is the chat feature, but there’s no way to specifically make a note on a patient to a provider. Outside of the tasking feature, it is difficult to communicate with a provider about a given patient. _

The medication aspect is complicated, but basically, we’re only able to see their current list of medications. Through a note search, you can see what medication was started or stopped at some point, but it’s not user-friendly at all. It’s very difficult to see, for instance with hypertension, what medications we may have tried and what medications the patient has been on before. We simply have what the patient is on right now, and we don’t even necessarily always have the start date for that medication, so we can’t see when it was added or when it was last adjusted. The information that we have there just isn’t detailed enough.

Is that with respect to your own medication history notes, or is that with respect to the Zus integration and any medication history that you get through that, or is it both?

No, not related to Zus – it’s just about what we ask our patients at intake. We ask what medications they’re taking as part of their medical history. So we have a list that we start with for patients, and then, depending on what our providers recommend for the patients, we’re going to change their medications along the way. It’s not easy to see that a particular patient came in on a specific medication and that we’ve discontinued that or that we started them on another medication – it’s difficult to see that trail.

There’s no timeline view or anything like that. We just have a solid narrative view. We can search by commands, but we can’t search across the concept or outside of the command framework, so it becomes challenging to find information.

Any features that work particularly well for you?

One thing that works well and that I’m always kind of impressed by is how easy it is to identify the correct pharmacies through which to order medications for our patients. I’m always surprised when I can find even the littlest hometown pharmacy in their list. So that’s very easy and helpful for us.

I would say that, while we definitely would like more business user interface tools allowing us to configure things and change things, we’re not reliant on those. The automations in Canvas work well, and the questionnaires work well. And I think that our team is comfortable with that functionality – we’ve very successfully built questionnaires and automations ourselves. So those are two things that I would highlight.

I’d highlight that, if we hadn’t figured out how to make automations work for us, we might have gone with a different EMR because this is crucial for us. There are no shortcuts or templates. I think what I was looking for was a templated note to be able to use, and so the automation serves that purpose for us.

From a reliability and stability standpoint, how has Canvas fared for you?

I think it’s been reliable. I used to work in the evening, and every now and again it would go offline, but overall it’s been reliable for us.

There have definitely been bugs. While we haven’t had issues from a platform stability perspective, there have definitely been some errors and bugs that we’ve brought to Canvas’ attention. We’ve sometimes been the first ones to come across them, and they’ve been pretty widespread sometimes.

For instance, our task list would always give me an error message – and again, our task list is what’s driving our workflows – so that was problematic. Some of the tasks’ due dates would show up incorrectly. That was something that destroyed my sanity for about six weeks. But the due dates would actually be different based on time zones, so someone who is on our team and on Eastern time would look at a task and would see that it was due tomorrow instead of today. And that is very important when it comes to certain activities related to clinical care and billing. That issue actually went on for about six weeks.

I would say that they’re very responsive to the issues that we bring up in Slack. They’re quick to prioritize bugs, but they’re not bug-free.

Do you have any insight into the developer experience or API in terms of how you’ve built on top of Canvas?

One of the things we’re doing is listening for different commands, whether it’s a “prescribe” command for medications or a “lab order” command, and then we’re generating follow-ups to patients that trigger for instance an SMS notification for that patient. I’m not sure how that’s actually strung together. I assume it has something to do with Canvas’ APIs and Customer.io, which we use for notifications, and probably Twilio, but I don’t actually know the specifics there.

Based on patient responses to those SMSs, they bring that information back into Canvas and can then complete or close out those tasks. We have that set up for medication reminders and lab reminders.

We also alluded to the fact that we use Canvas protocols to do deep links to other systems so we can open up a patient’s record in our messaging platform and on our remote monitoring platform in our own admin portal. At one point, one of our engineers started to bring in data directly to Canvas from our remote monitoring platform. We’ve since turned that off because it wasn’t possible to fine-tune the controls so that they didn’t completely overwhelm our charts with that data coming in from our patients.

In terms of integration, it sounds like you’re using the Zus integrations with Canvas. Are there any others that are out of the box?

I wouldn’t describe it as out of the box, but we have Candid Health in place as a claims clearinghouse.

And then Health Gorilla and Surescripts.

Generally speaking, what has the experience been like integrating those solutions and using them through Canvas?

I wasn’t part of the Candid Health implementation, but when I caught up with the team, I had the impression that it was perhaps one of the first times they were implementing.

Yeah, I think there may have been one other customer using Candid aside from us, which was surprising to us at first. And Candid did a lot of the implementation work and provided guidance to help us through that process.

I think it was the same for Zus – and I think it was more known for Zus; we knew this was going to be an early integration implementation for them.

I think it was the same. I think we sought out Candid. I know we had been looking at Zus, but I think it might have been reported to us that this was going to be available and it was going to be very easy, and in the end, it ended up involving more work than we were anticipating on our end. I think communication could have been a little bit better through that process.

Any additional comments to add around what the experience with their support or account management team has been like?

Our account manager is the best – he’s single-handedly made it so that we’ve been able to get to a spot, from a clinical workflow perspective, where we can proficiently use Canvas. For example, Canvas didn’t have a training track for providers. So I just pinged our account manager and asked him to put together a curated list of training videos for providers, and he’s awesome. He turns things around very quickly. He’s also a workflow hack wizard. We come to him with a problem. He knows that we don’t have the technical resources to solve something, and he comes up with a creative solution. We’ve done that with lab ordering, using the referral command to order to a lab that serves an uninsured patient population that didn’t have the funds to do a Health Gorilla integration. So he’s really gone above and beyond from an expectations standpoint.

Looking back, do you think your organization made the right decision going with Canvas?

Thinking back to when we were reconsidering, I think that we’ve grown together. But I think that our culture is that we work with what we have. And I’ve told our account manager many times how much I love Canvas. To me, it’s fun getting to know it and figuring things out. And I’m sure any EMR would have that, but it’s kind of exciting getting to understand how to make Canvas work for us.

When you think of the bigger picture, it also feels better to support the Canvases of the world, so yes.