CRM Aims to Finish the Job EHRs Started

A few pioneering healthcare providers have figured that because customer relationship management apps are so good at the people-oriented workflow details necessary for care coordination, the effort to customize CRM for healthcare is worth it.

The more I look into the status of meaningful use—it's a source of distress—the more I find beleaguered care coordinators using notebooks, Excel spreadsheets, and sticky notes to keep track of risk-stratified populations.

The reasons why they are not using EHRs to do this are varied, but fall into two general categories:

1. Too many EHRs either require care coordinators to adopt unfamiliar workflows.
2. EHRs require too much time, effort, training and retraining to provide workflows which are sufficiently tailored to the provider's way of doing things, or to the workflows that make the most sense for care coordinators.

All around, we see efforts to solve these problems. Some providers simply lay down the law that the EHR shall be used, even though it may not be anywhere near optimized for care coordinators. The low attestation rates for meaningful use in 2014 are evidence this approach has been unsuccessful.

Throwing Software at the Problem
Every year at HIMSS, we see a growing number of sprung-from-nowhere population health software applications designed to fill the gap in a best-of-breed fashion. At next year's HIMSS, a whole host of those will likely have vanished, replaced by other startups.

For my money, the most battle-tested care coordination software emerging is likely to be the customer relationship management (CRM) software represented by Salesforce and Microsoft Dynamics, which sales forces have been using out in the field for more than 15 years.

A few pioneering healthcare providers over the past decade figured that because CRM apps are so good at the kind of people-oriented workflow details which customers across many industries respond to so well, that the effort to customize CRM for healthcare would be worth it.

Thus, the care coordination crisis afflicting meaningful use is putting more and more CRM software on desks alongside EHR software. This "two panes of glass" approach is even prompting one provider, the University of California San Francisco, to purchase larger monitors, so care coordinators can have the EHR and the CRM open and side-by-side to get work done more efficiently.

Last week, Salesforce boiled down some of the early work of UCSF and other pioneering healthcare customers into its newly announced Health Cloud, a specific version of Salesforce optimized not only for care coordination, but for the kind of lead generation and call center productivity enhancement which are foreign to EHR software, but necessary to all businesses today, healthcare being no exception.

One reason healthcare can turn to these types of CRM solutions is that (with some effort) EHR data can now find its way out of EHRs into CRM systems via HL7 feeds and a growing selection of connecting middleware.

Another reason: Salesforce is comfortable signing hundreds of business associate agreements assuring that data stored in the Salesforce cloud is compliant with HIPAA regulations.

The popularization of CRM technology in healthcare is somewhat analogous to the way analytics technology has made the leap into healthcare. Vast and growing talent pools of analytics experts seasoned from tours of duty in the financial services sector, and legions of CRM rapid-application-development experts are increasingly at healthcare's beck and call.

The modern, application program interface (API)-based nature of cloud platforms mean projects are developed in weeks or months, as opposed to the years that such projects can take in traditional healthcare IT.

More Efficient Care Coordination
For example, at City of Hope National Medical Center in Duarte, California, a single nurse is now managing 150 to 200 cancer patients on their journey from diagnoses to outcomes, using a single Salesforce-built care coordination software system. Care coordinator positions, launched this year, allow staff to risk-stratify those cancer patients to determine which patients need additional support, says Shirley Johnson, senior vice president and chief nursing and patient care services officer at City of Hope.

City of Hope, UCSF, and a handful of other Salesforce healthcare customers are piloting Health Cloud before its general availability next spring.

"We knew there had to be a better way" than sticky-note reminders, Johnson says to an audience at Dreamforce, Salesforce's annual user convention, which brought more than 160,000 registered attendees to downtown San Francisco last week. "And that better way didn't take a year to develop."

CRMs, which typically could allow sales reps to track progress of sales prospects along a timeline, are being adapted to display to the entire care team episodes of care along a timeline. Johnson's team fine-tunes what Salesforce now calls "patient relationship management" workflow in collaboration with its new team of care coordinators.

One of the ways CRM turn the traditional EHR world topsy-turvy is the way the relationship between a prospective patient and a provider can begin. Instead or originating as a medical record number, a lead is generated in a prospect pipeline, much like any sales prospect.

Centralizing Key Data Elements 'in Context'
At Johns Hopkins Medicine International (JHI), a 450-employee unit of Johns Hopkins Medicine providing personalized, culturally-appropriate care for patients traveling to Hopkins from outside Maryland and the United States, an application built in Salesforce's Support Cloud manages coordination of patient visits where each day in the U.S. is a day of extraordinary patient expense and separation from distant loved ones.

"We are trying to centralize key data elements in context," including information drawn from the Hopkins Epic EHR so such coordination happens smoothly, says Fedor Vidal, IT director of JHI.

Yet another Health Cloud pilot site, Centura Health in Colorado, is using Salesforce for utilization management and referral management, and to receive notifications from the Colorado Health Information Exchange when a patient has been getting treatment outside the Centura network, which is about to go full-risk on 175,000 patients.

If it all sounds like things you thought the EHR was supposed to do on its own, well, that's what I think as well. That presents a challenge and an opportunity to CRM technology vendors such as Salesforce, and an equal challenge to traditional EHR vendors.

Lack of Data Flow to EHR
For one thing, what Salesforce does technically will not get anyone over the meaningful use attestation finish line. This is in no small part because data in CRMs, even HIPAA-protected data, has no easy way to flow back into the EHR.

The growth of APIs for EHRs has largely been restricted to read-only access so far. Where this all gets really interesting is that companies such as Salesforce are considering applying for certified modular EHR status for technologies such as Health Cloud.

If they succeed, the legacy EHRs may find themselves under enormous pressure from government and providers alike to allow technologies such as Health Cloud not only to read data out of EHRs, but to write data back in. That would require even more of an open kimono on the EHR vendors' parts – something in short supply so far.

A true ecosystem of sharing between the two worlds would allow UCSF and others to stop requiring dual-entry of care coordination data first into the CRM and then into the EHR.

For now, customers of CRM providers such as Salesforce has seem quite happy just to leave their Excel spreadsheets and sticky notes behind in order to have a simple second screen for unified care coordination, sitting alongside the EHR as necessary.

The next step, and it won't be long, will be to merge those two screens into one. This will allow CRM technology to help EHR technology do what it was supposed to be doing all along: Coordinate and manage longitudinal patient care at the population health level, while engaging patients at all points of their relationship with healthcare.