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Newcomers to healthcare quickly figure out the industry is a salad bowl of acronyms and abbreviations. Aside from a little annoyance and a lot of patient confusion, most are innocuous and don’t garner much reaction. However, there is one acronym that is guaranteed to elicit a variety of emotions – from appreciation from CIOs for digitizing a bunch of paper, to exasperation from health system executives who are dealing with its cost, to unmitigated hatred from most clinicians who are working with it every day.
And that’s “EHR”.
Electronic health record (EHR) software is quite simply the bane of many providers’ existence – technology they are generally required to use, but was not built with clinicians (or, for that matter, the modern healthcare system) in mind. While well-intentioned and with provider adoption around 90%, EHRs overall have been a disappointment and a national nightmare for a myriad of reasons.
From walled gardens to usability issues to a vendor oligopoly that stifles innovation and doesn’t leave much room for meaningful competition, some of the hurdles that have hindered large-scale healthcare transformation – like the migration to a value-based care system – can be attributed to the problems with EHRs.
However, in the background, there’s been a counter movement growing with entrepreneurs and investors starting to see white space forming – a space to spark a full EHR market disruption. Now, one of the leaders that could help lead that disruption today announced a significant haul of funding – an investment that signals a new level of maturity for the company.
Elation Health, an EHR platform that’s mainly used by primary care providers (PCPs), just raised $50 million in Series D funding to fuel its next stage of growth. The raise included a very interesting mix of investors, especially for those with high familiarity with the healthcare industry.
The round was co-led by Generation Investment Management, a firm that focuses on sustainable investments, and Ascension Ventures, which is a strategic investment fund whose partners include many of the top U.S. health systems. Additional participation came from Threshold Ventures, Ascend Partners and individual investors Fay Rotenberg and Jonathan Bush.
Those last two names are of particular note (and not just because they are married), but because they are industry stalwarts with unique pedigrees. Rotenberg is CEO of primary care startup Firefly, and Bush hardly needs an introduction, having co-founded and led his own EHR behemoth in athenahealth.
So, what kind of health tech company would singularly attract the attention of a sustainable investment firm, a fund made up of major health systems, top healthcare VCs, the CEO of a disruptive primary care provider, and a healthcare veteran who technically led a competitor?
The answer starts with the Elation founders’ background.
Family Practice Makes Perfect
Elation Health was founded in 2010 by siblings Kyna and Conan Fong, who serve as CEO and CXO (chief experience officer) respectively. The familial entrepreneurs literally grew up in healthcare, working in and around their father’s primary care practice that, interestingly, started in Canada before moving to the U.S.
“My father came home from work one day and said he just couldn’t deliver the type of personalized medicine he wanted to in the Canadian healthcare system,” said Kyna Fong in a recent interview. “So we picked up, moved to the U.S. and were tasked with basically figuring out an entirely new system, including everything from training staff to negotiating insurance contracts.”
Kyna said she worked in the clinic’s back office throughout high school helping her dad effectively keep the practice’s trains running. It was that firsthand experience that illuminated all she needed to know about the struggles that the average provider faces – familiar experiences that have led PCPs to experience higher rates of stress and burnout compared to some of their peers.
But, the Fong siblings didn’t immediately rush to start a company. Kyna first became a healthcare economist after studying game theory at Stanford, while her brother went into health IT sales. However, it was when they were thinking about how better to implement a technology strategy in their father’s practice that they realized that all of their EHR options were missing a key component – the patient view.
“We were pretty surprised and disappointed that we’d have to hire additional staff or see fewer patients because the IT systems were clearly built for billing and not for actual patient care,” said Kyna. “That led us down a path of curiosity where we ended up building something for our dad’s practice, and I guess the rest is history. That’s how Elation got off the ground.”
Today, Elation bills itself as “the platform for innovative primary care,” working with practices of all sizes and types, growing from its modest beginning to a rising EHR star. In the 12 years since launch, Elation has raised $108.5 million in total funding and counts as customers everything from large, enterprise-level health systems with dozens of PCPs down to independent, community-based PCPs that may have a single doctor.
The company also provides support to some of the more tech-savvy primary care upstarts like Crossover Health, Cityblock and Firefly Health (which makes sense considering Rotenberg’s investment). All told, Elation says that 24,000 clinicians use its technology who give care to 12.8 million patients.
Giving A Platform To Customers and Partners For A Value-Based World
The guiding principle behind Elation is its “clinical-first” platform that’s designed to support collaboration with the more than 300 technology and healthcare organization partners that make one million or more API calls to Elation’s platform a day. Elation’s open architecture allows partners, including its customers, to build on top of its platform to better suit their needs. That’s a key distinction from some EHRs that are notoriously inflexible and hard to work with.
“Traditional [EHR] systems are built around a claim. They are engineered around what is billable and their workflows drive towards making sure you bill as effectively as possible. It was only later that there was pressure to adopt the clinical piece, and once that part was integrated, it was almost secondary,” said Kyna. “Getting paid is important, but Elation optimizes around the patient view, creating workflows for the provider that enable them to provide greater care.”
Kyna also noted that, while Elation will help its customers operate in fee-for-service models, Elation’s longitudinal patient view allows providers to better succeed in increasingly common value-based care models that reward for higher quality. A 2019 study found that nearly 40% of healthcare dollars were tied to some kind of value-based program.
“You need to be shifting towards a system that rewards for value, not just volume. Then you start to think about all the things that relate to what happens between visits and not to just when the patient is in front of you in a traditional billable encounter,” said Kyna. “Patients are only with a provider a fraction of their time, but in a value-based system where you’re accountable to outcomes, it’s important that you have technology that helps you better drive behavioral change.”
While value-based models still have a ways to go before they fully take over the U.S. healthcare system, insurers are making them more of an imperative for PCPs. In fact, by 2021 more than 67,800 PCPs were in value-based relationships with one of the nation’s largest insurers, Humana. The continued transition won’t be easy on many PCPs.
Primary Care Challenges In A Rapidly Changing Landscape
It wasn’t like keeping a practice afloat in today’s environment was already a cakewalk. Even though primary care is a bedrock of community health, the primary care system in America is under tremendous pressure for many reasons – some of which Kyna wrote about in a recent Harvard Business Review opinion piece.
Thousands of primary care practices have closed – especially independent ones – a problem that COVID-19 exacerbated. Then there’s also been a lot of industry consolidation fueled by private equity. Primary care can be so tough that many health systems just accept that it will never make money and only offer it as a loss leader to act as a referral engine for higher-margin specialty care. There are all kinds of debates about what role primary care should play in the healthcare system of the future.
However, Elation is betting its business on a primary care-led future, believing it’s the only way to build a sustainable system that can achieve healthcare’s “Triple Aim.”
The small company named after a rainforest seems to agree. Amazon just sent shockwaves through the media-verse when it acquired concierge primary care provider One Medical for $3.9 billion, demonstrating it, too, believes in primary care’s future. However, that’s not all good news for the rest of the primary care industry, as it could put even more pressure on others – especially independent PCPs.
Amazon’s mastery over convenience and unlimited war chest to scale could fundamentally change the game for the average provider group. While not apples-to-apples, consider what happened to many SMB retailers when Amazon’s e-commerce operation started to dominate.
The bottom line for PCPs is that there is a minefield of issues to navigate, which is why EHR technology will play a critical role in their future.
Keys To Success
For Elation, many of its customers see its software as a key to both ensuring high-quality care while also reducing administrative burden. One such provider is a small independent primary care practice in Pittsburgh run by Rebecca L. Byard, MD.
“I found the [Elation’s] layout to be extremely intuitive, moving from record to record, or moving from place to place within a record. It just feels right. Very rarely do I have to go looking for something that I don’t know how to find,” said Byard, who also indicated she’s been frustrated with other EHRs. “I once used an EMR that I had to click through every item on the physical exam portion of the record, and it was exhausting and time-consuming.”
Byard also said she didn’t have to spend a lot of time training on Elation, and it was easy for her to access from anywhere. “I can capture data that comes from a fax directly into a patient’s chart, which helps me avoid printing and scanning things directly into the record.”
Another Elation customer, Crossover Health, implemented Elation’s software across 28 of its health centers – a process that took less than five weeks per clinic. The two organizations share a common view of a patient-centered care model that prioritizes providers’ relationships with their patients. It’s why Crossover Health uses technology to remove as many friction points and barriers to care as possible.
For example, Crossover Health redesigned its in-person health centers and check-in process, replacing the traditional waiting room with a “host” where patients can complete check-in up to 24 hours before a visit. Patients also can update their health data and complete health screeners at that time. That information is then available in their Elation chart in real-time and is incorporated into Crossover Health’s “clinical operating system” as metrics and potential areas for proactive follow-up. The result is a more accurate health record, a seamless patient experience and less wait times.
Crossover Health’s previous EHR required too many steps to achieve that level of integration. Without structured APIs, there was a lot of downstream maintenance, data synchronization challenges and other operational issues, which frustrated Crossover Health’s technology team.
Those routine issues that Elation helped smooth out for both Byard and Crossover Health may seem simple, but they represent the tedious tasks that add so much collective stress to provider workflows – stress that ultimately spills over to the patient experience and can affect care quality.
Scaling And Investing In Elation
If Elation continues to provide that level of support to PCPs at scale, then it’ll be harder for larger health systems to ignore. However, that also likely means the EHR incumbents will place a bigger target on the company’s back moving forward. Both challenges – scaling its business while also increasingly competing against the oligopoly – will require a lot of resources, which is why today’s investment is even more important. Elation’s investors are bullish.
“Unlike any, and I mean any, other EMR in the country, Elation allows customers to truly code their own alternatives to workflows. That’s huge and getting more important by the day,” said Bush. “While other amazing new companies offer awesome iframe or great low-code customizations, none provide comprehensive access to the workflow API and invite customers to customize what they have. You will start to see major medical groups – groups that can hire their own developers – make the switch [to Elation].”
Bush first met Kyna when she was working in her father’s practice and said he’s been a “tremendous fan” ever since. He believes the Fong siblings’ proximity to the problems providers experience while also having the development skills to address them are what gives Elation its “superpowers.”
Anthony Woolf, growth equity partner at co-lead investor Generation Investment Management, believed that Elation was different from all of the other EHRs his team evaluated.
“There are tons of EMRs that came out after the HITECH Act, but the majority of them have an awful product experience with low innovation,” said Woolf, who pointed to the poor Net Promoter Scores (NPS) that EHRs often have. “When we asked around to find out who actually liked their EHR, the only company people said to really look up was Elation. So we chased them down.”
The ethos of Woolf’s firm is the belief that sustainability and profitability don’t have to be mutually exclusive. He said Generation Investment Management focuses on companies that “genuinely care about their stakeholders and employees, their supply chain, and their impact on inequality,” which fit with Elation’s clinician- and patient-focused approach.
Woolf, who “loosely” leads the firm’s healthcare investments, also thinks a value-based future is critical for healthcare, serving as another reason why he liked Elation.
“We believe in a risk-based system because only when your doctor is accountable for all of your medical spending can they choose to focus on what’s most important first,” said Woolf. “So we’re strong supporters of value-based care, and it has to sit at the primary care level, which is why you need a strong technology system built to handle it.”
The Future Of Elation
With its new investment, Elation plans to focus its funds to expand its market reach and to add new features that will further unlock its fully API-enabled platform. The challenge, though, will be to keep convincing more and more providers that the development opportunities provided by the Elation platform are worth the hassle of ripping and replacing their current system. It’s one of the things that have made the established EHR vendors very sticky.
However, the ingredients for a disruption cycle in the EHR market are all present, and one thing Elation has proven is that it’s mature enough to compete.