CloudView Blog

Ideas, insight, and analysis to help physicians, medical groups and health systems stay informed and profitable in today's challenging health care environment.

Latest from Twitter

Submit A Post / Ask a Question

Have an idea for a future post that you'd like to share with our readers? Not looking to post a comment, but still want to share your thoughts? Send an email to


Disruptive Technology | Healthcare Policy & Reform | Models of Care

This “Goggle-eyed Radical” Wrote a Book

athenahealth CEO Jonathan BushToday I became Jonathan Bush, CEO, President… and author. Where Does It Hurt? An Entrepreneur’s Guide to Fixing Health Care has my name on the front and my picture on the jacket. But the book isn’t really about me. It’s about how we can allow more humanity to emerge in our health care system. The same American medical establishment that saves lives and performs wondrous miracles is also a $2.7 trillion industry in deep dysfunction. My time as an ambulance driver, a medic, owner of a failing birthing clinic and ultimately as CEO of athenahealth generated all of these plausible ideas for fixing our health care system. It’s time I share them with you, with enormous help from my co-author and friend Steve Baker, author of The Numerati, who worked considerable magic in helping translate my rants into fluid prose.

In Where Does it Hurt?, I share the stories of clients and others who are putting their vision into action and doing well by doing good. They’re disrupting the status quo through new business models, new payment models, and new technologies that give patients more control of their care while enhancing the physician-patient experience. For example, Florida Woman Care is disrupting hospital-centric systems by doing minimally invasive procedures at half the cost charged by hospitals. Hudson Headwaters, an FQHC and Medical Home in a rural, high-Medicaid area of upstate NY, is pioneering new care models and showing how a non-profit can operate with both mission and margin in mind. And the list goes on with example after example of the “crazy ones” who are chipping away at the status quo of the system. This book is as much a celebration of their work as it is a call to arms for other practices to follow suit.

It’s also a book about data. I believe that open data exchange is essential to the future of health care. When you are referred to a specialist, you shouldn’t have to fill out the same forms you filled out at the office down the street. Your health record should follow you, across doctor’s offices and across the country. And hospitals shouldn’t be scared of that. Big data is empowering to everyone. It will bolster the health care economy through competition by exposing rates and quality. Open data will enable shopping…and that is the big key to this necessary change. Shopping by doctors, shopping by employers, and ultimately by all of us. Of course, this is a thing that needs to sneak up gently on our fragile, sclerotic healthcare establishment, and with this book I have unburdened myself of all the tricks I can think of to accomplish this.

Thanks to Steve Baker and an awesome group of athenistas who were with me every step of the way, I’ve been able to find the right words, audacity and opportunity to share my book with all of you. If you do read it, I’d love to hear your thoughts on it. If you don’t (despite your best intentions) it seems to be about the same thickness as those little brass wheels on the bottom of antique coffees tables which are notorious for breaking off. So either way, I hope it serves you well.

Hear Jonathan Bush present ideas from his new book on May 21st as part of a virtual event athenahealth is hosting titled, Where Does It Hurt?” Register today for this free event.

Check out Jonathan Bush’s Google+ Profile. Follow @Jonathan_Bush on Twitter.

All Things EMR | Healthcare Policy & Reform | Meaningful Use

We Should Be Pushing Interoperability Boundaries, Not EHR Certification Timelines

Health IT stakeholders across the nation were recently asked to comment on criteria to define 2015 electronic health record (EHR) certification. Ostensibly, these criteria would allow EHR vendors to voluntarily certify their products to meet an updated set of standards by 2015.

Voluntarily? Even the Office of the National Coordinator (ONC), the party who issues the rule, admits that it expects such voluntary participation to be quite low. Why issue this proposed rule if only to make it voluntary? Perhaps to break ONC’s pattern of compressed regulation timelines by giving EHR developers an early preview of functionality that will be required for ONC’s upcoming 2017 certification rule, which in turn will be mandatory to comply with Stage 3 Meaningful Use. But even with that cushy deadline, industry stakeholders are pushing back.

Last week, the Electronic Health Records Association (EHRA) spoke out against the regulation, stating that “the proposed rule specifically does not respond to our repeated requests for final rules and all supporting materials and tools at least 18 months in advance of when providers and others expect certified products to be available.” (As if any other supporting evidence were needed for our decision last month to sever ties with this static group of software vendors.)

Unlike the EHRA, we appreciate this heads-up from the ONC. But as demonstrated by our 95.4% Meaningful Use attestation rate in 2013, our clients are thriving in the face of Meaningful Use requirements and timelines.

The ONC’s 2015 EHR Certification rule includes a handful of requirements that create tremendous value for both providers and patients—requirements such as more data-driven clinical decision support and advanced drug-drug and drug-allergy checks, to minimize the likelihood that patients are accidentally given prescriptions or procedures that may harm them. Is the industry really pushing back on this?

Not every requirement in the proposed regulation is perfect, of course, and frankly, some are outright awful, which I’ll show you some examples of later in the post. But the lens we use is not whether we have the time and resources to make changes (after all, this is 2014, if it still takes you 18 months to build and roll out elementary functionality, you are doing something wrong). Rather, we look at this rule in terms of the value it can bring to providers and patients, and ask whether the industry and government could invest in initiatives that will have even broader and more meaningful positive impact than the ones proposed.

Here’s an example: Consider that the rule calls on providers to be able to record a patient’s military service status, although it is wholly unimportant information for most clinical visits. Or that it suggests that providers record a patient’s occupation in a structured code, requiring providers to sort through a monstrous list of potential occupation codes. These are activities that only add to the time caregivers spend in front of their screen and away from patients.

Some requirements have even less value. One that’s associated with clinical quality suggests sharing a massive amount of granular patient information with the Centers for Medicare and Medicaid Services (CMS) for no apparent reason other than the technical ability to do so. Yet another revises—for the third time in four years!—the codes used to record a patient’s preferred language. Hardly the barn-burning tasks that will revolutionize health care.

What the national health care delivery system really needs is a true mandate for robust interoperability. Some of these capabilities are desperately needed, such as the ability to find a patient’s records wherever they may reside. What about creating provider directories to enable scalability of provider-to-provider and patient-to-provider electronic messaging? Where is the ability for providers to click a button and migrate all their data – clinical, quality, population health, patient communication – wherever they wish, without being held hostage by a poorly performing EHR? All of these critical pieces are superficially explored, if at all, in the proposed rule, but could prove so instrumental to the transformation of health care over the next few years.

To the ONC and the industry, we say: There is work to be done. We cannot and should not slow down… we are already far behind schedule. Let’s focus on pushing the boundaries of interoperability, openness, and clinical rigor. Let’s focus on the innovation it can enable, the silos it can break down, the lives it can improve, the costs it can eliminate. Now is the time to push. And push hard.

All Things EMR | Healthcare Policy & Reform

Sometimes Breaking Up Isn’t That Hard To Do

Dan Haley, athenahealth VP of Government AffairsThis week athenahealth resigned from the Electronic Health Records Association (EHRA), the trade association that ostensibly represents the collective interests of the EHR industry in the many Washington, D.C.-based policy debates that impact EHR vendors and, by extension, their care provider clients. Members since late 2011, we joined the EHRA hoping to utilize the organization as a forum to spread our often-distinct points of view on particular issues — like the then-relatively-new Meaningful Use program — that were gaining prominence in the national debate over healthcare reform.

We’ve all been in relationships where each partner tries, subtly and not so subtly, to change the other in fundamental ways. Those relationships go one of two ways: either one partner changes to suit the other or the relationship eventually breaks apart. There is an element of that dynamic in athenahealth’s breakup with the EHRA — but it isn’t the whole story.

At the end of the day, athenahealth left the EHRA because we never really belonged there in the first place. The EHRA was founded in 2004 by a group of EHR software vendors. Today, a decade into the age of cloud technology, the EHRA is still dominated and governed by a group of EHR software vendors.

That is not what we are. athenahealth is neither an EHR company, nor a software vendor. We operate as a services company that offers a cloud-based EHR as just one enabling component of our extensive suite of health IT services. Our public policy priorities are broader and more varied than those of the traditional software vendors that run the EHRA — and even where our priorities overlap, we’re too often on opposite sides of crucially important debates.

As a direct result of that frequent divergence, athenahealth is often obligated to explain to policymakers why we disagree with “our trade association.” This not only distracts from our point of view, it also undermines our credibility.

No single event led to our resignation, but some reasons for our parting of ways have come in the context of the Meaningful Use program. athenahealth steadfastly advocates for the aggressive timelines and high standards we believe are necessary to bring health information technology up to the standards of information technology used across the rest of the economy. One need only look at athenahealth’s latest Meaningful Use attestation statistics to understand just how significantly our clients’ results exceed the woeful norm. We are ready for 21st century standards, and we ensure that our clients are, too.

The EHRA, in contrast, consistently urges slower timelines, delayed deadlines, and lower bars. Why they do so is no mystery: many of their members’ static software systems are unable to meet Meaningful Use program timelines and standards. While we urge the Centers for Medicare & Medicaid Services (CMS) to publicly identify vendors whose provider clients seek “hardship” exemptions from looming program penalties, the EHRA presses just as hard to protect its members from the consequences of their failures by opposing any such disclosure.

In the days to come, we will work to identify other future-oriented health IT stakeholders to join with us in an effort to advance an innovation-friendly policy agenda in DC. And we’ll begin with the signatories to the five hard commitments set forth in our Health IT Code of Conduct (not one of whom is a member of the EHRA…).

With this effort, we’re not seeking to create a competitor to the EHRA so much as a higher-performing alternative — just as cloud-based health IT is increasingly viewed as a higher-performing alternative to anachronistic, static software platforms. One might say we’re performing a ‘rip and replace’ on our own outdated trade association.

If we can influence policy to better encourage innovation — to ultimately benefit care throughout the nation — perhaps a critical mass of caregivers will follow our lead…

Care Coordination | Health Information Exchange | Healthcare Policy & Reform

A Walk-Back, and Setback, for Sustainable HIE

Here at athenahealth, we’ve always held the view that the exchange of information is a two-way street and that the cost of information exchange should be shouldered by both sides.

This approach is common in many other industries — so common we take it for granted as the norm. For example, in the ATM industry, you don’t pay an ATM fee for in-network ATMs, but you pay a fee for out-of-network ATMs. In the long distance industry, receivers pay for 1-800 long distance calls. Allowing for either side to pay the communications fee has fueled widespread adoption of these basic transactions.

In 2011, as the government began its multi-billion dollar investment in EHRs, we formally asked the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services whether we could apply this same “in-network/out-of-network” model to health care transactions to accelerate the rate of adoption of electronic information exchange. For simplicity, we pegged the cost of a transaction at $1 — far less than most ATM fees. The OIG agreed with our approach and granted a historic, well-reasoned opinion which stated that “the efficient exchange of health information between Health Professionals is a laudable goal.”

This week they changed their mind.

We are disappointed with the OIG’s decision to reverse course and terminate its Advisory Opinion No. 11-18. As every provider and patient knows far too well, care coordination in health care today is a morass of inefficiency and lost opportunity. Clinical information is often not current or complete, and orders and referrals arrive incomplete or get lost in the shuffle. Redundant work saps staff efficiency and drives up costs. Providers are too often left in the dark as to whether their patients get the care they ordered. A study from the New England Journal of Medicine found that in 49% of referrals the receiving physician was given no information and in 55% of referrals the ordering physician got no information back from the receiving physician. This congested, gummed up system fails providers, patients, and health systems.

The OIG’s walk-back closes one promising path forward to a functioning, sustainable economic model for health information exchange. It represents a setback for any patient who has ever been turned away from a doctor’s office because their referral paperwork hasn’t been received, or handed a clipboard to provide information that a practice should already have had. And it’s a setback for one of the few bipartisan objectives of health reform: care coordination.

Disappointed and frustrated as we are with this policy reversal, we’re as committed as ever to our vision of connecting a nationwide network of care. Over the past fifteen years, we have created a strong national network of 50,000 providers and 3,000 receivers (labs, pharmacies, imaging centers, etc.), all sharing data openly and seamlessly to support the care of 40 million patients nationwide. And with our recent addition of Epocrates, more than 300,000 physicians are connecting into, and benefiting from, this network. While the OIG reversal eliminates one clear path to a functional model for health information exchange, we are confident there are other ways to get where we need to go. We will continue to work by every lawful means with innovative officials, providers, and industry colleagues to advance health care toward a fully modern data economy where a sustainable and fair economic model enables data to flow freely to improve outcomes and lower costs.

Who’s in?

Healthcare Policy & Reform | ICD-10

ICD-10 Dismay

Way back, when we were still struggling to run a successful birthing practice called Athena Women’s Health, I shared a dank, cramped house in San Diego with Jonathan Bush, my brother Todd, and the other athenahealth co-founders. I slept on a mattress on the floor with a 30-pound tower computer as a headboard and for months would wake up every day, roll out of bed, and write code. Line by line, I built rules around medical billing claims so providers could get paid faster and more accurately for delivering care. Down the road at the clinic, the providers were consumed with weightier challenges, like lowering the C-section rate and reducing NICU days. It struck me then, and still does, that we had landed on a fair and smart division of labor. Providers would focus on delivering care and we’d invent technology and services to wick away the paperwork and hassles, and get the caregivers paid for doing the right thing.

To my mind, that is the fundamental social contract — or it should be — behind the $31 billion health IT (HIT) industry that’s grown up around US caregivers. Which is why news of the vote to once again delay the ICD-10 transition is disappointing, and symptomatic of an ongoing breach of that contract by technology vendors. Whether the adoption of an already two-decades-old coding system is going to meaningfully transform care is certainly up for debate. But as a proxy for the HIT industry’s ability to handle change on behalf of providers, the latest ICD-10 delay is a troubling canary in the coal mine.

Over the last five years, the government has spent more than $20 billion of taxpayer money to install electronic health record (EHR) technologies, many of which cannot implement a change in diagnosis codes that the rest of the world implemented years ago—in some nations, more than a decade ago. ICD-10 readiness for providers is about much more than the availability of mere technical functionality; it’s about having the support necessary to successfully achieve ICD-10 compliance, which includes things like training and business processes. That the government felt compelled to delay the ICD-10 transition reflects not a failure of health care providers, but a failing health information technology industry that’s unable to support providers in navigating change.

Health care providers need and deserve technology partners that will step up and do what it takes to ensure their success in meeting the complex demands of our changing health care system: from the ICD-10 transition to the Meaningful Use program, from the transition to risk-based payments to the demands of care coordination. The government needs to stop subsidizing dysfunction by accommodating technology vendors that, time and time again, leave providers high and dry.

In recent years, caregivers have been asked to do backflips to absorb huge changes to their practices, their approach to care, and the ways they get paid. If health care providers are ever to achieve the ambitious triple aim around cost, quality, and the patient experience, they’re going to need technology partners that can move beyond excuses to keep up their end of the bargain.

Rocket Fuel