For those in the health IT industry, athenahealth is a household name. The company was founded in 1997 by former HHS Chief Technology Officer Todd Park and current athenahealth CEO, president Jonathan Bush and has since grown to a $1 billion publicly traded company.

A lot has happened since 1997. Some of the events are obvious but others – such as the push for artificial intelligence in healthcare – are a little less so. Bush met up with Healthcare Dive during the HIMSS17 conference to discuss what's changed since the publication of his 2014 book "Where Does It Hurt?" with athena, how the company is prepping for a more networked approach and who the new "crazy ones" in healthcare are.

What has happened in the last two years

"Between 2014 and today, I think the single headline that has emerged is digital health," Bush said. The company started its marketplace in 2011 where even if a company was internet-based, they were still going to market as a typical enterprise software company.

"What has since developed at athena and in the market is the emergence of the potential for platform," Bush said. In 2014, the number of times in the network a patient at one practice would show up at another (and thus increasing the making the ability for network effect) was more-than-slightly slim. Last year, it was 22.5% of the time, he said.

"That's an environmental shift," he said. "Similarly, the number of mobile-first, digital apps and plays and ecosystems for them has gone up by thousands and thousands of percent."

Another major change in the last two years is that athena is able to pivot toward a more networked approach. Armed with a new CTO and organizational design, the company aims go to market presupposing revenue will come from a diverse set of platforms that connect to the athena's meta-platform.

"Our tactic has always been do more and more cool s--- that attract doctors to use your platform so that eventually with everyone there you kind of pull out the pin and everyone is connected," Bush said. "Imagine an IDN that is truly integrated and national in nature that doesn't have any tax IDs or contracts or buildings, but just is the integration layer of healthcare. That is our strategic intent. We felt as though we were earning the right to pivot with our core business services."

The ability to connect doctors to each other and to new allied sources of care including digital health apps and other companies requires a new architecture and style of business, according to Bush.

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"Our tactic has always been do more and more cool s--- that attract doctors to use your platform so that eventually with everyone there you kind of pull out the pin and everyone is connected."

Jonathan Bush

CEO, President, athenahealth

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What's next for athena

The move toward a more networked healthcare industry is causing legacy companies to rethink their business strategies. Bush welcomes this change. "Within athena, we've outrun our underlying architecture," Bush said. "Athena is either the youngest, coolest, hottest dinosaur or kind of a toothy mammal, depending on how you look at it." 

After weathering the EMR/Meaningful Use gauntlet, athenahealth's current raison d'etre is flat out cash savings. According to Bush, the number of non-provider FTEs that exist in a practice per doctor has been slowly ticking up and athenahealth is looking to help providers cut that number down via technology. "That's the core 2017," Bush said. 

A second move athena is working on this year is to create a national patient index across the U.S. and a national calendar that acts like Open Table or TripAdvisor. In theory, a patient could make an appointment with any doctor on athenaNet or any doctor not on athenaNet that wants to use the athenaNet calendar.  

Why it may matter to physicians, health systems

Bush said there will likely be a flattening or decline in government subsidies coming to providers with President Donald Trump's administration (a trend Bush thinks would've occurred if Hillary Clinton won as well). New digital health companies and alternative care settings are shifting the supply and demand of healthcare services. Doctors and hospitals, before such companies, had exclusive control over the supply. As air pockets of supply pop in and hospitals' empty beds start to be more of a fiscal drag, it matters to connect to patients. Hospital systems went from wanting to create a closed vacuum-pack system to realizing referrals in a post-retail clinic and post-telemedicine world are needed to grow organically without mergers, according to Bush.

The reduction in subsidies alongside the changing dynamics in the supply and demand of healthcare services will push some power away from hospitals, health systems. 

Bush hopes the open athena calendar and the ability to gain and capitate on net new lives will entice physicians to sign up for the tool. "We are going to offer doctors freedom from their old calendars," Bush said. "You could just get onto the national calendar asset. If they do that, they're going to get a lot more appointments, and if they don't, they're going to suffer a loss of market share. We're expecting once people get it, they'll get on there. That will be what 2018 is about."

Network Medicine

Last month, the company announced a series of partnerships to roll out different "network medicine" campaigns.

"After you start using artificial intelligence to get the lame and lonely work out of the doctor's life, you start to form clinical conclusions," Bush said. "Because we've got everybody streamed through one instance of one application, we can start to see consistencies and inconsistencies in order choices, in patient compliance and what doctors are doing about it. We're starting to just now get insight into clinical practices that work and don't work through bio-surveillance and watching what goes on in our network. I think over the years, that will be the biggest deal about athena."

The company announced three initial efforts in February for 2017: preventing medication safety risks during pregnancy, managing opioids and chronic conditions, and adjusting cholesterol treatment for cardiovascular patients.

In athena's 2016 full-year SEC filing, Bush wrote, “Our expanding network now connects care across nearly 88,000 providers, nearly 86 million patients, and over 143,000 network endpoints." He is betting on the ability to harness the power of the database to form conclusions. Bush expects other providers will sign up as they search to cut some costs and as more lives, data populate the network, greater insights are expected to follow. "Hopefully it's a harbinger of something that will be essential in five years," he said.

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"Our second move, which we're starting on this year, is to create a common front door to athena and create a national patient index across the whole country and a national calendar."

Jonathan Bush

CEO, President, athenahealth

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The new "Crazy Ones"

In "Where Does It Hurt?", Bush dedicates a chapter to individuals on the periphery of the industry looking to shake it up while making big changes. He knights them as "The Crazy Ones". In 2014, he wrote, "They're all but invisible to the policy crowd in Washington. few of them hire lobbyists...These people are rough-hewn and break the old rules. And they're engaged in radical and unusual behaviors. They're busy making money in healthcare by building something new and appealing for shoppers."

In 2011, around $895 million was put into digital health by venture capitalists, according to Bush, adding, "That's less money than tickets at the CMS parking garage." In 2016, it was $4.2 billion over 296 deals, slightly down from $4,6 billion in 2015 over 273 deals.

Bush notes the changing dynamics of healthcare in the last two years and the amount of money flowing into the space have changed "the crazy ones" roster. "There’s a new generation that are purely De Novo venture backed," he said. He pointed out the following companies as members of the new class:

• StartUp Health - In 2011, StartUp Health introduced a model for transforming health by organizing and supporting a global army of entrepreneurs called Health Transformers. StartUp Health is investing in 10 Health Moonshots with the long-term goal of improving the health and well-being of everyone in the world. 
• Amino - Amino aims to connect everyone to the best healthcare possible. Powered by a database that includes nearly every practicing doctor in America and experiences from more than 188 million patients, Amino's service allows people to make decisions about where to get care. 
• Privia Health - Privia Health is a physician practice management and population health technology company that partners with doctors to help keep people healthy, prevent disease and improve care coordination in-between office visits. 
• Teladoc - Teladoc uses telephone and videoconferencing to provide on-demand remote medical care via mobile devices, the internet, video and phone.

Why they matter

A Physicians Advocacy Institute study published in September 2016 found the percentage of physicians employed by hospitals or health systems rose 86% from 2012 to 2015, from 95,000 to more than 140,000. As of mid-2015, 38% of all U.S. physicians were employed by hospitals and health systems, according to the study.

Bush states much of that activity can be attributed to primary care and cardiology groups that were were opponents of the ACA and HITECH Act. "Now they want to be back as the masters of their destiny," Bush said.

The new "crazy ones" are showing up as alternatives to hospital systems and some doctors are flipping over to those entities whose strategic intent is somewhat the opposite from hospital-based employers. If that continues, that could have a huge impact on cost but also on the power base.

According to Bush, hospitals are in trouble. A decent chunk of hospital beds are empty (Bush says 38%) and many made big health IT investments. "If those doctors start to pull out, two things happen," Bush said. "One, they don't amortize their IT investment over as many people, transactions, doctors, activities, earning power. Two, their ability to keep admissions rate up is eroded. They may actually lose admissions or diagnostics. That compounding could be the noise that these kinds of new crazy ones make."