“In theory, theory and practice are the same. In practice, they are not.”

An athenahealth client recently reminded me of this quote attributed to Michelangelo, which nicely summarizes one of the main themes that emerged as part of the America Health Insurance Plans (AHIP) Accountable Care Organization (ACO) Summit in Washington D.C. on Wednesday. In theory, ACOs lead to more integrated care and sustainable cost growth throughout the health care system; in practice, ACOs are creating issues in the market that should be proactively addressed via regulation and the forming of new ACOs.

Some details about this first-ever Summit: The idea originated from a conversation that our CEO Jonathan Bush had late last year with AHIP’s CEO Karen Ignagni. During their conversation, the two leaders discussed health plans and independent practices’ shared concerns regarding some of the more acute, unintended consequences of the ACO, model. One particular concern is that market consolidation under large hospital systems—including the acquisition of independent and small-practice physicians for the purpose of gaining market power—seems to be increasingly prevalent. Additionally, smaller practices are often excluded from forming ACOs due to structural impediments (e.g. regulatory bias, staffing constraints, reimbursement effects).

The AHIP ACO program included presentations from a wide variety of experts, including an antitrust enforcement officer from the Department of Justice, private sector antitrust attorneys, a self-described healthcare “futurist,” and athenahealth board member Charlie Baker. 150 key influencers attended the event, from D.C. leaders and hospital executives, to caregivers and commercial payers.

athenahealth sponsored a portion of the program, which included Jonathan describing our efforts to help clients thrive in risk-based reimbursement models while remaining independent; a lively discussion between Jonathan and Congressman Bill Cassidy, MD of Louisiana; and a panel of our clients: Mark Girard, MD, from Steward Health Care Network, David Slingerland, MD, of Hudson Headwaters Health Network and Marc Feingold, MD.

I viewed the summit as a meaningful call to arms for legislators, regulators, payers, hospital executives, and providers alike. We were excited to play a part and proud of our clients for providing tangible examples of how ACO regulation is affecting and influencing the market. And we are looking forward to continue advocating for independent providers and to creating services that enable clients to thrive—no matter the reimbursement model.

I recently connected with the HL7 Standards blog’s Chad Johnson (@OchoTex) for a fun “5 question” Q&A. We touched on CommonWell, the athenahealth Code of Conduct, cloud security, the unique characteristics of athenahealth culture that allow us to be so engaged in policy conversations, and the always-around-the-corner “Big EMR Switch.” I’ve included some highlights from our conversation below, but you can also check out the full interview.

If you feel compelled to ask, “Dan, how much did you pay Chad to ask these softball questions?” that would not be an unfair question. But I assure you, Chad came up with these all on his own.

1. What do you think the CommonWell Health Alliance will have accomplished a year from now?

When it comes to CommonWell, “where will you be in a year?” is exactly the correct question. The first stage of the Alliance is a one-year pilot program, to test the basic assumptions about the model and ensure that it works the way the founding companies intend. At the end of that first year, we expect the members to be sharing data between and among their systems. If we didn’t expect that, athenahealth would not be involved. A lot of work will go into making that happen.

The CommonWell Health Alliance represents a real effort to snap together some of the vertebrae to create that national information backbone. After years of annual conferences where executives of the big electronic medical record (EMR) companies stood up and solemnly pledged to solve the interoperability problem that still plagues health IT, this year at HIMSS some heavy-hitters finally took a tangible step toward that goal. We’re pleased and excited to be a part of that. We view it as a step more than a solution in and of itself, but it is an important and necessary step.

2. What struck me as interesting about the Code of Conduct was the first provision, which is a vow to pay for and facilitate the transfer of a provider’s clinical data if they choose another EMR vendor, which can be a huge endeavor. Why did athenahealth think this challenge was necessary? And do you think your competitors will sign on?

Here’s the thing about our proposed Health Information Industry Code of Conduct: it isn’t a challenge. We aren’t daring our peer companies to sign on; we’re asking them to agree to a core set of very simple principles that we believe can, if broadly adopted, help pull our industry into the 21st century. No legalese, no weasel-words, no out-clauses. Just five basic principles that we think and hope our industry can get behind. When one of our peer companies signs on we put its logo right up there on the signatory page with ours. It isn’t supposed to be “an athenahealth thing.”

Because we were able to ask ourselves a simple question–what basic propositions do we think could materially impact our industry?—and then reduce those principles to a clear, concise, one-page document, we think we managed to put forward a proposed Code that is easily understood, broadly appealing, and capable of attracting support from a wide range of forward-thinking industry stakeholders. We are also able to push on our industries in a way that consensus groups cannot do.

The provision you asked about is a perfect example. We believe absolutely that no doctor should be locked into an EMR out of fear of having to lose his or her clinical data, or having to start from scratch with a new system. That kind of ‘lock-in-by-incompetence’ model wouldn’t be accepted in any other industry in 2013. It should not be accepted in health care. A company that is confident in the quality of its services should have no problem committing to pay for data transfer for a client who decides to move on.

3. Security is a prime concern in health IT and cloud offerings are often the target of criticism. John Halamka even described it as “your mess run by someone else.” What steps are you taking to assure your clients and prospects that clinical data is just as secure in the cloud as it is in a hosted solution?

Done correctly, cloud-based services are “your mess, cleaned up and run by someone else.” Underlying the athenahealth vision is a basic approach that characterizes every service we provide to doctors, and every service we contemplate providing in the future: we look constantly for new and better ways to take administrative burdens out of care provider workflows so that they can concentrate on patient care. It allows us not only to organize our clients’ information but also to actually do the work for our clients, in real time. Moreover, while we’re doing that work, our clients have real-time, always-available access to their information. The impact of that difference in approach cannot be overstated. Cloud services aren’t an alternative to a hosted solution. Cloud services are a different proposition entirely.

As to security, clinical data is not “just as secure in the cloud as it is in a hosted solution.” Assuming one is dealing with a competent, responsible cloud provider, it can be more secure. Do a Google search for news stories on health data breaches and you find story after story reflecting the same basic incident patterns: institutions printing out medical records and losing track of the paper, which no technology can solve; and human beings misplacing portable media (laptops and thumb drives) containing PHI. Cloud services obviously eliminate the possibility of the latter because protected data is stored remotely, on highly-secure servers, not locally on any media that can be left in a cab.

4. athenahealth representatives seem more willing than other EMR vendors to engage in public conversations and “make waves.” That’s definitely refreshing, but I imagine it causes your marketing team to stock up on antacids. What is it about your company and its culture that fosters this type of open dialogue with the health IT community?

Stated simply, it starts from the top. We have a CEO, Jonathan Bush, who shoots from the hip all day long, every day. He’s the last person who would ever come down on an employee for maybe getting a little bit too enthusiastic in communicating our company point of view on the important issues impacting our industry. In fact, not only am I free to engage in the public conversations you ask about, but it is part of my job. We want athenahealth to be part of those conversations. On any number of issues, we have a point of view that is markedly distinct from—sometimes diametrically opposed to—the rest of our industry. So in a very real sense we need to be part of those conversations. We cannot rely on others to make our arguments for us.

5. I’ve read that Black Book has named 2013 the “year of the great EMR vendor switch.” Since switching EMRs is no small task — especially if the provider intends on migrating old data – do you think this prediction will come true?

I certainly hope it will. I don’t think an impartial observer would argue with the proposition that there are a lot of lousy products out there, and a lot of fed-up care providers stuck using them. In my Capitol Hill wanderings, I often say that health IT lags a decade behind the rest of the information economy. The next time you are in a doctor’s office, take a look over the check-in desk and tell me I’m wrong. In some offices, the technology being used is more than a decade behind.

I have to believe that, at some point, a critical mass of doctors will not accept that the technology they are forced to use in their professional lives is so exasperatingly inferior to the technology they (and their kids!) use in every other aspect of their lives. At that point, they will finally start to demand better of their vendors. That inevitability, in my view, is the best hope for an eventual “great EMR vendor switch.”

Of course, it would help if the government would stop paying doctors to buy static software-based technology that should have gone the way of the dodo around the end of the last century… but that is a whole other set of questions.

I welcome any and all questions regarding our work down in D.C. Comment below or find me on Twitter at @DanHaley5.

In this fourth and final post (see Parts I, II and III) on Jonathan Bush’ in-depth interview with theEditorial.com, we focus less on innovation and health care, and more on the eccentric entrepreneur behind the curtain—Jonathan himself. Read on to learn what it’s like to grow up a Bush, who gave Jonathan a break when he needed it, and a day in the life of JB (one of my personal favorites from the series).

Be sure to catch the full interview here. – Michelle, Social Media Manager

Was it more interesting to be in a startup in your basement than riding a booming $2.7 billion-market-cap company?

JB:
I don’t feel remotely less engaged than I did then. The motivation there was survival. Not biological death, but the death of athenahealth. I would hire someone and I’d say, ‘Here’s how it’s going to work. We’re going to pay you enough to cover your Visa, so you don’t roll over your Visa. We’re going to give you stock and if it works, you’re going to be rich and if it doesn’t, you’re going to have a great resume item and story for what you were doing for the last three years.’ I did a startup. I tried to revolutionize birth.

Today I rarely think about whether athenahealth will go under, but what I think about all the time is will it matter? Will we get enough steam built up and is our nose hard enough that we can make a dent in this amorphous, numb sort of Orwellian system? And that’s motivating because it’s so much bigger than us. I mean, we’re big compared to where we were but compared to health care, we’re like if ticks could get ticks.

Is there someone who gave you a break when you needed a chance?

JB:
Fred Frigoletto. Then chairman of OB-GYN at Mass General called me back when I was a business school student and helped me work on my midwife model. I wasn’t even a med student…that was cool. And Mitch Besser and Bill Schwartz and Cindy Dickinson in San Diego, who basically joint ventured on the first women’s center. That was huge.

The other one would be my uncle George. We had all these elaborate models that showed how the midwifery thing would work and I met with his financial advisor, a guy named Tony Duke from Bessemer, and Uncle George called me and he wanted to know one thing. ‘What I couldn’t tell from all this excellent work is, do you believe in it? In your heart, do you really believe in this thing?’ And I said I really believed in it. And he said, ‘I think that’s the most important thing and Bar and I are in. Goodbye! Love you.’ That was it.

You come from a very powerful American family. How does that affect you on your path as an entrepreneur?

JB:
I think my party line is that the wind is sometimes at my back as a result of that name and sometimes in my face as a result of that name, and that it averages out. I have so many cousins and uncles and grandparents who have established themselves and have done really good work at games that were already well played, that I was scared away from even trying to play the familiar.

I had a lot of love and a lot of unconditional positive regard from my parents, which clashed dramatically with the practical reality of the battlefield which is that every job, investment bank, political sphere, golf, tennis, had been done way better than I could ever do it and so how did I reconcile. I think that forced me further out into the ecosystem. I had to be an outlier.

Describe a typical day.

JB:
It depends on the day of the week, but on a day like today, I wake up at six. I do my breathing for fifteen minutes. I am here now in this. ‘I’ on the inhale, ‘am’ on the exhale. And then read a couple pages of The Presence Process. Michael Brown recommended it. I wake the first kids, get them started and then the second kids at 7:00. I leave at 7:25 with the two kids that need to go far and the other two kids walk. My fifth child is in college. Today is admin day so I work until 3:00 when I pick up my youngest. I try to get one on one with each kid in some way. It’s my chance to be a father.

Today is one of two days each week committed to administration of the company: writing for the internal audience, meeting one-on-one with members of my team and helping them with their journeys. It’s meeting with my wife, Mandy. On Monday or Friday, we have lunch and we go through our calendar. Fridays, I spend three hours with my team and we go through everything that they’re working on, a day a month on PR, a day a quarter on investor relations, a day a week on client and operations experience. We have town meetings at different offices. We have six offices. (From India to Belfast, Maine to the headquarters in Watertown, and it’s 900+ employees.)

You have five kids. Where is your favorite place to take them in Cambridge?

JB:
I love the Cambridge Skating and Tennis Club and with one daughter, we do gymnastics every Sunday. That’s like a highlight of my week.

Is there a quote you live by?

JB:
Blank or die trying. Doesn’t matter what.

Follow Jonathan on Twitter at @Jonathan_Bush.

Last week, I was fortunate enough to experience TEDMED, an event held in D.C. each year that features brilliant short talks and artistic performances that celebrate the power of unexpected connections and facilitates a conversation about how to get to a future in health care we all want.

During the event, the feeling of excitement, innovation and intellect was palpable. On the first evening of the four-day conference, hundreds of caregivers, scientists, innovators, entrepreneurs, students and scholars poured into “The Hive,” an outdoor tent right off the Kennedy Center that showcased TEDMED speakers from up high (literally: an image of each speaker hung from the tent’s ceiling, the work of Rhode Island School of Design [RISD]students.) The tent event was appropriately named—the buzz of what’s possible to make health care better roared from every beanbag chair, couch, booth and high-top table.

There is a certain symmetry that so much teaching and learning takes place at TEDMED since these are two of the core tenants of the athenahealth culture. Some of the highlights for me as a first-time attendee:

• Our CEO Jonathan Bush talked about profit, people and frontiers in health care. He talked about how the profit motives of health care are broken and must change, called for innovation on the edge of health care. He reminded the audience how people like John Mackey from WholeFoods and Steve Jobs from Apple took on the status quo of what arguably was working in their respective industries: ordinary grocery stores and standard personal computing. Jonathan shared that these companies saw a frontier where they could bring more to their markets, in the form of widely available, fresh local food and an alternative to conventional PCs. He called upon disruptors, the “crazy ones,” those willing to tackle new frontiers to “come along and make health care better.” The message was well received.
• Jay Walker, curator of TEDMED, made many appearances on the stage, continually bringing very old, rare books from his personal library to share with the audience. Among his powerful messages was that our world view is not always right, and he used various scientific views from the past to illustrate this. Walker’s point is that we just don’t know what about our current view is wrong. He encouraged everyone to be open to different interpretations as we work to discover ways to drive change and improvement in health care.
• The President of RISD, John Maeda, spoke about the impact of design on health care and encouraged greater attention to design and leadership from those in the crowd, encouraging people to climb “the mountain” (take on new challenges). Maeda suggests each participant not be afraid to fall—there’s always the opportunity to make your way back to the summit or learn something along the way.
• America Bracho, the Executive Director of Latino Health Access, a center for health promotion and disease prevention, was among my favorite TEDMED presenters, reminding us all that there is no “magic bullet” in health care and that each patient needs to be treated uniquely. Bracho recounted stories of diabetic women described as “non-compliant patients” in urban, low-income settings who were told to take more walks for exercise and to stop eating tortillas. What their doctor did not know was a) their neighborhoods were not safe to walk through and, b) tortillas were all their family had to eat. Bracho urged doctors to listen, engage and find community advocates (patients) who could extend treatment goals by teaching others like them in the community how to be healthier.
• Amy Abernethy, a medical oncologist and palliative medicine physician, talked about patient information, likening information donation to blood donation and questioning why patients can’t give information like they do blood, to be pooled together to help others in need.
• Rafael Yuste, from the $100 million-backed Brain Initiative, reminded scientists in the audience to “dream,” as discovery emerges from such passion-driven dreams. U.S. Surgeon General Regina Benjamin shared accounts of how she works at a national level to help people “get moving” for their health.
• Self-proclaimed icon, Richard Simmons, got a smaller group moving: The TEDMED crowd. Simmons had some of the smartest people from the medical community up on stage dancing and supporting his life-long commitment to better health through exercise, with his almost incomprehensible sense of optimism, silliness and genuine kindness.
• The last item I learned about—and certainly not least—was The Smartphone Physical —how cool is that?! The idea that clinically focused apps and mobile device add-ons can be used to complete a patient checkup, doing things like monitoring lung capacity and confirming ear health. I was quickly able to confirm the health of my eardrum and could even see a video of the inside of my ear, insight that could easily be stored for later comparison if my doctor had the right toolset or if it was emailed to me. This technology could serve extremely valuable for parents whose kids tend to suffer from repeated ear infections, making it easier to know if a trip to the doctor is necessary.

Needless to say, TEDMED offered a lot to absorb as a learner, and great teachers to learn from. But the themes of each ‘lesson’ focused squarely on innovation, passion and partnership, whether the talks were driven by data, success stories, visions for application, or simply the act of inspiring discussion.

Dear Friends of athenahealth,

As most of you know by now, the Boston Marathon bombing suspects were pursued last night and early this morning a stone’s throw from our office in Watertown Mass. As the manhunt continues, that office is closed for the day and employees living in surrounding areas are staying home.

That said, we are open for business. WIDE open.

Our NOC (Network Operation Center) team is humming along at its emergency backup location. Our CSC (client support center) is taking calls and supporting clients at FULL capacity in our Belfast, Maine Operations Center. Our claim operations, pre-certification operations and Coordinator operations are also running at FULL capacity at our Belfast, Birmingham, and Chennai offices. Remittance operations are all up and running in Belfast and Chennai, but with the redundant facility in Watertown closed for the day there may be some small delay in remittance posting. Offices in New Jersey, Alpharetta, Austin, San Mateo, Birmingham, and Raleigh-Durham are open and supporting all our care providers on athenahealth and Epocrates. In short, we are rocking away!

Though the exact motives of this attack are still unclear, the point of this kind of terrorism is to generate enough widespread fear and panic that a society freezes up and stops functioning.

At athenahealth, we don’t allow that. We don’t flinch.

Together we are making our small contribution to that collective statement of our society.

It is the very openness and prosperity created by our freedom of motion and thought that is the real target. It is not the unfortunate victims who happen to be in the way of the blast that they are after; it is the millions who may be frozen by their actions. The goal of terrorism is to erode our confidence so we freeze up. They want to terrorize us. We of athenaNation are honored to be among those who get to send a message to the world that this tactic fails where we are concerned. Our Boston Mayor Thomas Menino said “I have never loved this city more. I have never loved this commonwealth more.”

I agree and feel the same about our dear company.

Our thoughts and prayers go the victims of the terrorist attack, and to those who died and were injured during the manhunt. And as hard as it is to do so, let’s also spare some love for the sad, broken souls who thought this was a good idea.

Jonathan