Can the company maintain high standards-and private status-despite explosive growth?

It shouldn't be surprising that the Westborough, Mass.-based eClinicalWorks (ECW) came in as one of the top three vendors of interest voted by HCI's readers. According to a February 2009 survey from the Orem, Utah-based KLAS, 24 percent of providers considered the privately held company when making an electronic medical record (EMR) purchase. That's some achievement, considering that in 2004 that number was zero percent. The fact that ECW has zoomed to the top of providers' radar so quickly - along with satisfaction ratings that approach 100 percent-only adds to the company's mystique.

“They frankly changed the game,” says Mark Wagner, lead author of a February KLAS report that profiled the company. “One of the greatest things about ECW is that they don't believe there's anything they can't do - and so far they've delivered.”

“There's a fearlessness aspect in everything we do,” agrees Girish Kumar Navani, CEO and founder of the company. “We're just not afraid, and I think that conviction makes people want to know more about us.”

In addition to that fearlessness, adds Wagner, part of the intrigue is that the company has an unusual willingness to tackle problems from a technology standpoint. “They've proven they are willing to deliver on the things they tackle - and most deliveries are on time and issue free,” he says. “That's a great thing.”

A logical question, given the lack of originality that many agree is endemic in the HIT industry, is why aren't more companies copying the ECW model? Wagner says the answer is simple: Building a successful clinical application is not easy.

Navani agrees with that, but says there's more to it, namely the ECW culture. “To copy a company is more than copying the product,” he says. “You have to copy all our principles along with the product.”

The ECW product, a unified EMR and practice management solution that is scalable to practices of all sizes, is something that physicians seem to adore. “They came out with a slick interface that physicians love and that's one of the primary reasons they're doing so well,” says Wagner. “Physicians look at it and go, ‘It's simple, it's easy, I like it.’”

In addition to a product that was almost universally hailed by physicians, the company was revolutionary in its approach to pricing. “The game-changer, in addition to the interface for physicians,” says Wagner, “is the pricing model, which was cheap, and it was transparent.” In addition, he adds, total cost of ownership is what is says it is. “That's a huge issue for providers frustrated and tired of being nickel- and dimed for everything they need done by a vendor.”

There is a third factor in the company's rocketing success - speed. As an example, less than a year after introducing ECW 8.0, 94 percent of the company’s 6,500 contracts, representing 40,000 providers, are live on the latest version.

Why such easy and fast upgrades? “A lot of us come from a strong technology background,” says Sam Bhat, vice president of sales and a co-founder of the company (Bhat himself came to eClinicalWorks from the Waltham, Mass.-based Novell) “We understand that when we build the technology, it's important to have the mechanism to distribute that technology to our customers,” he adds. At ECW, all distribution is web-based. Bhat looks at the historical challenges vendors have had in releasing upgrades to all their customers. “That's one thing that's different with us,” he says. “We are able to deploy and get improvements into the physicians' hands quickly.”

One of the greatest things about ECW is that they don't believe there's anything they can't do - and so far they've delivered.

And the speed of ECW's product enhancements mirrors that of its distribution. The company follows the principles of extreme programming (employed by such tech firms as the Mountain View, Calif.-based Google), rather than traditional waterfall development, and, says Navani, the result is that ECW comes out with significant enhancements every six months. “It makes it harder for others to copy us; and in addition, our customers know we're listening to them,” he says.

eClinicalWorks' developers also utilize a hub and spoke technology for integration that significantly cuts down on the time to build interfaces. “We do the integration with a health center once, host that hub in our data center, and the practices just connect to that hub as a spoke,” says Bhat. “We don't have to go through the effort of point to point connectors, like other vendors who have to reinvent the wheel many times.”

Finally, the company has uniquely embraced a certain sort of transparency for its customers (and indeed, its competitors as well) about what it does well and what it doesn't. For example, anyone can log into ECW's user groups online and find out what the customers are asking for - in addition to what issues they are raising. “We think that's a strength, because it allows us to move faster,” says Navani. “It creates a sense of urgency in the company that says, ‘We'd better do this, because everyone can see it!’”

That type of transparency is a big part of the culture at ECW- and at ECW, culture, it seems, is everything.

It begins, says Navani with the company's approach of running a business with common sense, versus dictation by Wall Street. The company was organized, he says so that it could stay agile, even at 100 million dollars. eClinicalWorks is structured into teams, with no one person more than one level away from the CEO.

Some have said that Navani makes every decision in the company, but he insists that isn't true. “People think I do everything, but I don't,” he says. “We have a team structure that lends itself to quick decision making and I get too much of the credit for putting it all together.” Navani adds that his formula for being a good leader is engaging responsibility by giving people the leverage to act on decisions. “Yet people know they don't have to fear making the wrong one,” he adds.

Those fast decisions have played a part in the version 8.0 release of ECW, which has additional components like real time clinical decision support at point of care. Bhat says it's multi-dimensional to more than, say, age, gender and diagnosis; providers can add lab results or structured data to the mix. In addition to fast deployment to almost all of its users, Bhat says ECW kept the transition to Version 8 a smooth one by maintaining some backward compatibility so the end users don't experience a big change. That, and lots of education. “We invest a lot of resources in educating our customers with online webinars and education programs at no cost,” says Bhat. “That's what we believe in. If you don't educate your customers about the new technology they may not use it.”

The game-changer, in addition to the interface for physicians is the pricing model, which was cheap, and it was transparent.

In addition to Version 8.0, ECW is seeing a big uptick in signups for its hosted solution. With 10 data centers nationwide, its emphasis on remote hosting is expected to grow. “If you consider the sheer volume of providers that are not live today, you have to see a hosted model become more prevalent,” says Wagner. “The success of the SaaS model in billing solutions is giving people confidence in the clinical model.” Wagner believes that remote software-as-a-service (SaaS) models like that of ECW can solve the problem of lengthy deployments. “Our understanding at KLAS is that ECW is about 30 percent remote-hosted - and that includes ECW being deployed through hospital groups.

Navani says that ECW's current growth is being evenly distributed between large enterprise clients, and individual private practices and federally qualified health centers. “You will see us continue to march forward on those fronts,” he says. “We will also figure out how to deploy large communities which will give us a new level of strength.”

But just how robust is that hospital interface? Though Wagner says though it's a story that still remains to be told, the fact that there is a solution in place definitely gives ECW a leg up. Indeed, the solution has been actively deployed by the New York City Department of Health to 2,000 physicians under a regional model of deployment, and Wagner says hospitals are considering ECW for their physician groups are keenly aware of that. “This New York City deployment has given ECW a huge leg up because of the kind of work they've had to do to deliver for New York” he says. “They've picked up all kinds of experience and opportunity to develop solutions for the city that then becomes part of the total solution they offer elsewhere.”

One question many ask is if ECW can continue to maintain its explosive level of group - particularly in an HIT environment where staffing shortages are a very real problem. “From an industry-wide perspective there aren't enough resources to manage the existing work,” says Wagner, who concedes though that this is not unique to ECW, because of their sustained explosive growth it will be an acute issue for them.

Navani doesn't see this as a problem. “ECW has grown rapidly, and how did we manage that?” he asks. “We figured out that growing talent was a core competency we had to build.” He says that ECW has already built the org structure and training programs. “That's one of the reasons we think we are positioned for this growth - because we've already done it.”

In addition, Navani says ECW has traditionally looked outside the HIT industry for talent - and today, that's turning out to be a plus. “Now that the economy is not that great, we can get people out of banking, finance and technology from other sectors as long as they have the right basic platform of analytical thinking, good communication, and responsibility as characteristics.” He maintains that ECW implementations start with 24 hours of signing, will full implementation within 8-12 weeks. “That's the model we are going to stick with,” he says - in addition to aggressively hiring. ECW recently crossed the 1000 employee mark.

That growth should continue because, according to Wagner, clinicians love the product, and the paradigm of the traditional PM has changed. “The clinical side of the shop is calling the shots,” he says. In the old traditional PM model they didn't care, but the old solutions are not flying anymore.”

Navani says there is one other factor that he sees contributing to the company's ongoing success, and that is its private rather than public status. “We quietly but confidently have avoided the notion of ever going public,” he says. We focus on employees and customers rather than focusing on investors.” He says that the company's belief is that to build strong customer relationships, it has to have long-term goals. “If we think it's something that needs to be done for a customer, we find a way to get it done without getting too caught up in ‘how much will we make if we do that?’” says Navani. “The thinking is simple-at the end of the day, all we do is to make our customers more successful.”

Healthcare Informatics 2010 June;27(6):53-56