Jonathan Bush, the forever loquacious, occasionally foul-mouthed and mostly unscripted CEO of cloud EHR company athenahealth, got the audience cracking up at the annual Stanford Medicine X conference in Palo Alto, California when he took the stage, declaring:
“Shit, I have nothing visceral or profound for you.”
He was referring to the unenviable position of having to follow the moving presentations of patients and artists that preceded his keynote on Saturday. This handicap notwithstanding, Bush managed to inform and entertain the audience with his tech-enabled vision for healthcare.
Later, in an interview with MedCity News, he talked about the future of information exchange and electronic health records. Here’s a slightly edited version of the conversation.
MedCity: If you were a hospital CIO, what would you demand of EHR vendors.
Bush: I don’t believe there should be EHR vendors. I believe records should be national networks like cable companies. I think if I were a CIO, I would sign on to a national network like athenahealth and I would not attempt to build my own biosphere of clinical information.
I would be humble enough to know that most of the time patients I receive have charts before they arrive [at my hospital] and I would like to be connected to wherever they came from. Most of the time patients I see will go somewhere else and would benefit from whatever information I added to the pile.
This is hard for CIOs because CIOs have gone from the back room to the board room over the past 20 years partly because of giant capital expenditures to build largely isolated offline electronic health records. And I agree that an electronic health record is better than a paper health record, but this is 2016. An electronic health record is not remotely as good as a national electronic record network.
MedCity: But given that Epic has a large market penetration, how do you contend with that? If you were a hospital CIO and you had Epic, what would you ask of them?
Bush: I think I would ask them to connect and that’s starting to happen. For years and years hospital CIOs were asking Epic not to connect because they thought, ‘We will buy up all the doctors and they won’t be able to escape and all their referrals would come to us because the only way you can refer anything is through Epic and the only thing on this copy of Epic is us. So we’ll get of our specialists, and we’ll get all the referrals.’
What hospitals found is that doctors would verbally tell the patient where to go and the patient would go wherever they want. And they also found that a lot of patients were being aggregated not by the primary care practices that they bought but new purveyors of primary care like retail clinics and urgent cares. The hospitals needed to connect to those because they wanted those referrals. So they suddenly went from how closed can you make us to how open can you make us.
What we’re doing now is that we are connecting to most of the Epic hospitals in the country and that’s been something that Epic has just allowed us to do in the last couple of months.
MedCity: So they are opening up…
Bush: They are opening up and I am cautiously optimistic. And we are providing services on top of that. So even if the hospitals is doing its record keeping on Epic, as long as we can get access to the clinical record data, then we can do population health, we can do patient outreach … and theoretically someday update the record at Epic.
I believe what will happen because Epic is largely run by good people and their customers are largely good people, is that the pressure has built to a degree that not only will they let us in to see the record but eventually start writing to it.
I don’t think doctors will hold EHRs in their hands in five years. I think they’ll be on Epocrates (used by docs to look up drug info) or some other app and they’ll call those records like you pull down a story on Audible or you pull down a movie to your device. So you stream it and then it goes back. You don’t keep it.
MedCity: Tell me what you can do with Epic today.
Bush: What they are letting us do is pull CCDs out of the Epic database. CCDs are continuity of care documents – it’s a government mandated, almost like a pdf. It’s like an electronic fax. Judy (Faulkner, CEO of Epic) has built a nonprofit that has a patient key that’s lets you figure out whether my John Smith is this same John Smith in Epic and match, and so we have built a matching service off of that.
MedCity: How does that help the patient?
Bush: So if you check into a cardiology practice here in town on athenaNet, we can quietly search all the Epic installations within 50 miles to see whether you have been in any of those facilities and then say ‘Ah I found you. This person has been to this hospital. This person has been to this hospital. Here’s what’s in the charts.’
MedCity: And how did that conversation come about with Epic?
Bush: Well for seven years, they told us to pound sand and (then) a series of events built. We’ve been getting more and more of the retail clinics, and the hospitals that are on Epic have been more and more needy of those referrals.
The other is that Epic lost the Department of Defense contract for doing the whole military after winning all of the feature function bake-offs because of their inability to suck in the charts of the soldiers from wherever they were.
And the third was the House Energy and Commerce committee started to subpoena Epic executives charging Epic of stealing federal dollars under the Meaningful Use Act (because their systems didn’t encourage data sharing). Epic didn’t steal under the Meaningful Use Act; they didn’t attest to the Meaningful Use Act. Epic’s customers did and it’s Epic’s customers responsibility.
And Meaningful Use doesn’t really require you to be that interoperable. So Epic did the technical, legal thing which is their only obligation, but lot of Congressmen and Senators were pissed because they thought they were getting something else.
MedCity: What’s the roadblock to interoperability?
Bush: I think the primary problem is the business model. There isn’t a way to profit from doing the extra mile that you would need to do to have integrated information. So the elaborate kind of final solution talk that you hear at all these conferences is to move everybody to full-risk contracts where suddenly you don’t want to do duplicate tests because that’s lost profit to you. That’s certainly true.
But there’s lot of simple things that could happen.
If a specialist gets a patient electronically from a primary care doctor, and actually you do a time-in-motion study on the work that that specialist’s staff has to do to get that person’s chart prepared and ready for the specialist to see, it’s like $45. What if the specialist could give the primary care doctor 20 blank fields and say, ‘If you fill these in for me, I will pay you $20 for a patient, and by the way here’s my calendar and you can book the patient?’
That’s illegal, but it doesn’t have to be illegal.
There’s a lot of things that are shy of turning a doctor into an insurance company. There are venture-backed companies that are starting up and growing quickly that are essentially buying primary care practices and trying to disrupt the insurance company. They are interesting and ambitious and they are going to be game changers.
But that’s a very complicated, risky, expensive way to get to clinical information integration. Just making it legal to pay someone for integrated clinical information would be a huge thing. And the number of people that are ready to take on the financial risk of being an insurance company is a much smaller number than the number of people that would be glad to figure out a way to pay for electronic information to leave their office in exchange for 20 bucks.
MedCity: You can now tap into Epic’s databases and eventually feel that you can even write on top of their medical records. What about the cybersecurity issues that naturally will arise?
Ten percent of all ambulatory care happens through athenaNet, but if we can get at all of Epic’s and Cerner’s databases we’re talking about most of medicine is available through athenaNet. That could change the pace of innovation not just for digital health but for providing healthcare, for providers.
Certainly we can afford better information security people than most community hospitals can (a reference to the California community hospital that got hacked using ransomware and which had to pay up to get their systems back online). The flip side of course is that if you hack us, you get a lot more access to data than a community hospital.
But that’s like saying if you build a super highway, won’t cars be going faster?Won’t therefore somebody be killed. Yes. But we all know that the benefits dramatically outstrip the risks.
The key is for athenahealth to be super vigilant to just over check ourselves so that we don’t slow down this inevitable movement to the cloud with some chilling, embarrassing event.
Photo: Stanford Medicine X