athenahealth's Jonathan Bush: Washington needs to think less

athenahealth CEO Jonathan Bush is never one to mince words, especially when it comes to his love--or lack thereof--for software based systems, as well as the government's efforts to oversee (or as he puts it, "ghettoize") innovation in healthcare. FierceHealthIT caught up with Bush at HIMSS11 in Orlando to talk about those issues, as well as his company's new announced collaboration with Microsoft, pairing the former's cloud-based services with the latter's Amalga platform to create an electronic health solution designed to improve the connectivity and communication between hospitals, physicians and patients.

FHIT: Talk a little bit about athenahealth's announced collaboration with Microsoft. What are you trying to accomplish?

Bush: We're doing a deal with Microsoft that has this product called Amalga, which is a relatively sophisticated tool for amalgamating data from lots of different legacy systems and agents. What that allows is for a hospital to have a integrated picture of inpatient and outpatient data between employed and nonemployed doctors across a wide footprint. That sort of flies in the face of, or allows hospitals to not do the thing that they used to have to do to get one picture, which was literally employ and own everything, and then put everything on one system, even if the system they had before was fine.

It's a software based application, which kind of bums me out. I wish it was a cloud-based thing. I'd really like to find a partner to pick up Amalga and host it for us and really be the full setup. Our whole theory is, you get paid for results. You do the upfront work, you the setup, you do the interfaces, you do the training, then, if it works, you get a share of the benefit, which I think is an enabler of much more innovation. 

You don't want users to rely on a system just because someone else did. That's why God gave us the CIO of the year; you have a million CIOs putting in the same systems--over here you've got a total disaster, but over here you've got a total success. Now how can that be true? What is wrong with that system that somebody can use it badly and get a disaster after putting all that money in. Why isn't the vendor more of a fiduciary? And that's what the cloud is all about. It's 'I'm not going to make you pay for this system, I'm going to make you pay for the thing you wanted.' You don't pay to use Amazon if you don't buy a book. You pay for the book! And if Amazon is doing a great job then you'll buy two books.

FHIT: Along those lines, how big do you think the cloud is going to be in the near future for healthcare?

Bush: There's absolutely no question that traditional software license sales will end. It doesn't make any sense. There's no ability to exchange information. The only thing that may happen is some providers today, some of these hospital systems, may become clouds of their own--buy legacy software and serve it up in some way. You know, Rube Goldberg clouds, clouds with metal centers. But mostly, of course, what'll happen is new entrants. It'll be mostly new entrants. A new entrant will probably get disrupted when the really new entrants come in. We'll wipe out old ones. 

There'll be millions and millions of point solutions--and of course we'll learn how to exchanged information. Once there's an economic model where the sender benefits and the receiver benefits from exchanging information--not a state HIE but an actual business deal where everybody benefits financially in the immediate term--then there'll be exchange going on all the time, all over the place. And, the room for more biodiversity in the business, and the number of businesses that can play, will explode. Eighty percent of the names in this room won't be growing organically, at all, in five years. Like, zero. They might still exist, you know, they might hold their existing customers hostage, but...they'll be managing themselves into acceptable decline.

FHIT: I read your interview with HIStalk--so, to clarify, you don't think anyone needs to worry about funding for technology efforts disappearing?

Bush: I think that entrepreneurs that want to start technology companies don't need to worry about finding investment money. I absolutely think that providers will find, and CIOs will find their IT budgets evaporating. And, I think they know it, and I think that's why they're rushing to blow every dollar they can possibly get their hands on as quickly as possible.

FHIT: What do you attribute to athenahealth's recent financial success, especially in Q4?

Bush: Well I think if you're the only cloud-based player in the market, you can suck pretty bad and still do pretty well. So we've got that going for us. I also think we did a nice job. I think that our client stays and our hours dropped to an all-time low. The percentage of claims that we could get handled for them on the first try reached an all-time high. We began reconciling clients' bank statements for them; literally, like, everything. We began taking credit cards for them and reconciling them. We got to over 90 percent of remittance advice could be handled electronically potential. Those things just add up to a great product.

FHIT: Is there anything here at HIMSS that really piques your interest this year?

Bush: I knew that I would have no time, so I didn't even check. I wish I had, because I think it's neat to walk around. It's like a boat show. People are like 'oh, our turbo-thruster upgrade will blah, blah, blah.' I just didn't pull myself together to see it.

I'm terribly concerned by a couple of rumors I heard that the government--you know, the guys from [ONC head David] Blumenthal's operation--is talking about trying to micromanage the user experience for physicians on EMRs. As if they know how the screen should look.

FHIT: Does anybody know, at this point?

Bush: Of course nobody knows. The idea of legislating that? The government is having an unfortunate consequence from the biodiversity of the software ecosystem in healthcare. Because they create this massive deadline from crashing down, people revert to the established, old-fashioned vendors because they don't know anything else. I don't blame them. I get it. You know, we're impatient. We need to get outcomes during our administration and all that [stuff].

I really preferred the Bush Administration's approach, which was a more open-ended, 'hey, I'll let money flow more easily and I'm setting a goal where I want to see you get there by 2014' [type of thing]. I think that more subtle approach is more market friendly and results in a broader base of ideas and then the bad ones get wiped out. Today the bad ones get used. They get bought and rolled out by force, and you see millions of doctors on bad systems that they don't like.

They made these announcements at HIMSS and I thought to myself, 'I don't know what they mean.' I haven't gotten to the bottom of them, but the idea of a bunch of guys in Washington trying to out think a thousand companies that make EMRs on what they should do--they need to go the other way. They need to think less. They need to think a ton less and let the market think more. I don't know what's going to happen.

FHIT: Speaking of Blumenthal, any thoughts on who should replace him?

Bush: I imagine they'll put Farzad [Mostashari] in, just because he's been in there, he's doing a lot of the thinking work, he's very charismatic and very brilliant and has had a lot of results. I assume he'll step in. They'd be nuts to not give him a crack at it. I really, really, really, really, REALLY don't agree with the way that he thinks about the world. But...you know, they love him. The whole 'top-down, our-people-from-Harvard-know-more-than-the-average-person-and-we-will-make-the-average-person-become-better-like-us' philosophy...if I had to be enslaved, I would want to be enslaved by Farzad. I just don't want to be enslaved. I eat vegetables and I work out and I hug people and I'm a good listener and I'm a good dad and I'm a good husband...great! But anyway, I still don't want to be enslaved.

It's not just because I don't want to at a visceral level personally, which is also true, but I just believe that less good ideas emerge when people are enslaved. They can't talk, they can't experiment, there's no range of motion. Healthcare has literally ghettoized crazy ideas. They do not let people do crazy ideas. What if a hospital paid a doctor $5 every time a doctor sent a patient to them completely electronically from any system. In Norman? Jail term. Minimum, one-and-a-half years.

Anybody can stumble drunk into any cash machine in the world, jam their [card] in, put in their four digits and out comes rupees, or whatever's supposed to come out. How does that work? Kickbacks. That cash machine gets $2 from you and an interchange fee from the bank and everybody pays a little piece for the transaction afterwords. Mortgages are originated by one guy and underwritten by 50 banks. Stock is traded in an instant electronically. Those are a series of electronic and business arrangements that allow seamless exchange! That's not a crime! It's called a free market! It's just unbelievable to me, instead these guys are thinking top down.

FHIT: Will that culture ever change and if so, what will force that change? 

Bush: Well, one thing could happen. Depending on how badly the Republicans act, if they act too badly then the pendulum will start going the other way. If they behave well, and the problem isn't solved--and enough neutering gestures aren't made by the administration--then they'll lose the Senate and the White House, and then WHOOOMPH! 

The other thing that'll happen, even if the top-down types stay in, is that that will result in no innovation other than wonderful ideas coming out of Washington, and that will cause the cost of healthcare to eclipse our ability to pay for it more quickly. It's happening now, but it'll just continue. And then there will be a period of time where the government simply can't fund the all-you-can-eat buffet. So they'll put wait lists and ques and they'll do the things that other nationalized health systems do, which will then cause demand to rise up and out of the government and you'll see just like in schools, a private sector emerge on top of the sediment of the public sector.

So everybody in America has access to free public schools, but everyone in America who can afford it doesn't go. It used to be the private schools, and then it was the Catholic schools and the private schools, then it's the private schools and the Catholic schools and the public universities, and also the online universities, where you can get a little certificate. You don't get your MBA, but you get this and you get that and maybe in five years it adds up to an MBA.

Imagine what could happen if all that money that went into these public schools was available in that ecosystem. But we don't want to lose our public schools. It's too big a risk. And I think healthcare is the same way. Even if it would be better, we don't want to go through the valley of death to get there.

This interview has been edited and condensed.

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