Jonathan Bush on why the industry needs digital health entrepreneurship
Sometimes profane but always provocative, athenahealth's CEO & President Jonathan Bush has been pushing for a more digitally-savvy healthcare industry since he co-founded the company with former U.S. CTO Todd Park in 1997. These days, athena is evolving an aggressive marketing play ("Unbreak Healthcare") to not only highlight the fragmented bits of healthcare but to offer a vision for what "unbroken" healthcare looks like. They're doing this through a slightly changed tone and launched athenaInsight last month to help drive change through data.
Bush visited the Health 2.0 digital health conference in Santa Clara, California last week where he explained his vision for Health 3.0 at an athenahealth-sponsored talk show hosted by Dr. Zubin Damania aka ZDoggMD. Healthcare Dive sat down with Bush who touched on topics such as digital health ventures, collaborations across the industry, and where consumer-driven technology may actually impact clinical care. This interview has been edited and condensed for clarity.
Healthcare Dive: Can you explain Health 3.0?
athenahealth CEO & President Jonathan Bush: Paper to computer, computer to network. It’s the notion of healthcare on the internet. The idea of standalone computers running enterprise software is a freaking dinosaur concept. We need something that’s internet native and has everybody on one platform. From a societal public health perspective, it’s obviously what was meant when Congress passed the HITECH Act. They thought they were passing the Healthcare Internet Act and what they got was thousands and thousands and thousands of isolated installations of software from the '80s and '90s.
About half or two-thirds of everything we do in the doctor’s office could actually be done digitally. If we did that, we could shop for care not just amongst the specialists, shrinks and radiologists in a town but anywhere in the country. What has been a largely monopolized local market for care could become a much more liquid, more powerful national market for care from patients' point of view. From the provider’s point of view, their opportunity to grow would no longer be constrained by their geography but could grow into the rest of the country. For a tertiary, quadiary academic medical center that is basically bathing with a wire brush in shame for what they’ve done to their prices – beating up the local health plans to get their rates up – the idea that you can actually grow outside of your geography is inspiring.
Could this Health 3.0/expanded market presence idea drive down healthcare prices?
Bush: I think you’d have both options. I think you’d have the opportunity to buy up and spend more because you want the best care, whatever you believe that to be. And I believe you’ll have the opportunity to buy down. I also think suppliers will have that opportunity, for example, to say, "Our radiologists aren’t busy. Our brain scan is empty. Let’s cut our prices in half and let anyone with a risk contract that wants a half price brain scan in." I hope it goes both ways.
Where do you see your company going?
Bush: We really need an athenaNet 3.0 just like healthcare needs a healthcare 3.0. We need to re-factor our patient databases so that if you’re a patient for any doctor on athenaNet, you’re capable of being a fully-connected patent for every other doctor on athenaNet and on any other EHR. That pivoting of athenaNet around patient centricity is something that our clients haven’t wanted us to do until now. But in an era of population health where they need market share in order to survive, we have their buy-in. That’s exciting for us. Now we’re able to do – little by little – a rewrite of athenaNet to pivot toward patient centricity. We also have enough doctors and enough instances of patients that it matters. If we had pivoted with 1% market share, it would’ve been a solar eclipse that you saw your chart in two different places. Now we got around 80 million patient records, saw 142 million office visits last year in 2015 across 36 million people. Thirteen million showed up in more than one practice. That’s enough to start to matter and where that network effect starts to be valuable for our patients and for the efficiency for doctors. I think of it as an EHN, an electronic health network. That’s my 3.0.
What should other health IT companies think of when it comes to moving toward network operations/data collaboration?
Bush: You have to be a better citizen than you’d have to be in an industry sector that wasn’t quasi-governmental. FHIR is kind of dumb but we use it. We make an effort at being constructive citizens in these government-centric innovation communities. You can’t just throw your arms up and refuse because one of these things might work and you’ll be left behind but it’s not like we’re fixing it. We’re still chipping away 20 years in so we have a tendency to participate in two or three of anything. We’re rewriting our own APIs. We’re re-platforming a lot of athenaNet’s shared service architecture, making that shared service architecture available to other companies that want to access our charts or our docs but we’re [also] appropriately using the FHIR protocols.
How do efforts like athenaInsight play into athenahealth’s long-term vision?
Bush: Industrial strength internets have in common important characteristics. One is administrative simplification. Most of athenahealth's life has been about administrative simplification. If you do enough of that well enough and get enough people on a single instance of platform, you can start to get into network knowledge. That is where you can start helping [doctors] not just do the administrative work better but actually involve yourself in the clinical work and help them. The athenaInsight team has already been able to tap tens of thousands of doctors on the shoulder and we never began to imagine that in our first 20 years. For example, we found people at risk of Zika in the Zika zip codes in line with them learning from the CDC that they were in Zika zip codes. Right now we’re just toying with it and seeing what’s possible; we’re sharing what we see/know with providers and patients who could benefit from knowing what we know.
Our first, primary responsibility to our clients is to help them operate better. We’re just now being able to do this focused by specialty. For example, we’ve got five specialties where we know and track client performance against meaningful, clinical sentinels that equate with high performance. That’s just now beginning and that’s where we’ll add to the regular oversight we do overall for operations and get into sentinel metrics for clinical decisions. We now have one doctor for each of these specialties on staff who's only job it is to accumulate insights from the medical colleges and other places and then test how our doctors are doing against those clinical insights nationally and coach them into alignment.
At the risk of hubris, the fact that there’s an athenaNet out there with 10,000 medical groups attached to it makes it a little more appealing to become a health IT internet entrepreneur because at least there are 10,000 medical groups that you could sell to with a single connection. That’s why [the conference] Health 2.0 is so important to me because these guys are breathing life into the idea of digital health entrepreneurship.
What are your thoughts on digital health?
Bush: Healthcare desperately needs orthogonal energy. There aren't enough people sick enough at any given time to make the mass adoption curve that we enjoy with cell phones and other sectors happen in healthcare. The “instrument itself” movement — the Fitbit, Under Armour crowd — is dragging along the 12 of us that really need the thing. A device that would only be built for diabetics that would be prescribed by a doctor would be a clunky, ridiculous Rube Goldberg contraption that cost thousands of dollars and had to be recharged every 10 minutes. But if you make something available to millions of wealthy, affluent high-buy consumers, now all of a sudden you’re in the Apple Watch world and you can put a multi-hundred million dollar diamond of an invention on your wrist for $600.
When you see direct-to-consumer health tech, not all the players will win and many are developed without evidence-based research. Where is their place in the healthcare industry?
Bush: I’m always looking for black swans that will wake me up and one of the big protectors that allow for inefficiency and ineffectiveness to last for a long time is evidence-based. It’s not that there’s anything wrong with evidence-based but in a fee-for-service world where you’re trying to manage costs, no one’s going to allow a new procedure code through the door unless there’s been a lot of evidence. So, there are these enormous politics and spends around evidence and tiny tweaks don’t get researched sufficiently to get through the evidence-based because there’s no one making enough money on the other side to spend $300 million on researching it.
In a full-risk environment where a group of doctors basically are the insurance company, Medicare and the government rolled into one, they could be A/B testing the way Facebook does. You could imagine in such a risk environment the same vast acceleration of the R&D cycle. We do one test a month, one release a month. Other companies faster than us are testing constantly and the steepness of the learning curve that is possible in that world has never been seen in healthcare.
If a product was designed to only serve people who are in the market for a really expensive, rechargeable vacuum cleaner, the product could never work. You need a billion people to get a thousand vacuum cleaners pumped out a day. That’s the basic math and that’s why the instrumented itself movement is so appealing to me. It’s ironic because these [healthy well] are the last people in the world that need healthcare but they’re going to drag through the five who have chronic health issues who are going to be using the same technology to try and dig themselves out of the grave.
But does that scale?
Bush: The five users don’t scale unless you can waterski behind the technologies for the 5 million instruments-itself people. That’s the point. What we need to do is connect to waterski behind [Under Armour CEO] Kevin Plank. He’s bought up enough apps. He’s got 130 million people collecting data on their physical self.
Providers at risk will buy and learn to use products that can move the needle for them and they won’t have to wait for peer-reviewed clinical efficacy trials blessed by FDA to do it. Even if they didn’t have to wait for that, it still wouldn’t be there because there actually aren’t enough people in the U.S. that are sick. So the winners in healthcare have to be the ones that figure out how to slipstream behind that mainstream internet, that mainstream nonclinical use internet.
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