How Jonathan Bush Plans to Build the Health Care Internet

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Jonathan Bush, the high profile CEO of athenahealth, has a grand vision of the future of health care and it involves building a “health care Internet.” In this world, primary care physicians are power brokers, connecting and referring patients to a cloud-based network of super-specialists that can care for patients regardless of their geographic proximity.

Primary care physicians will be able to find specialists anywhere in the country, even the world, with highly specific skills and knowledge for their most complex patients.

Patients will have the advantage of being cared for by doctors who have treated hundreds of patients just like them, instead of by doctors who may only see patients with their specific disorder a few times in their careers.

It sounds compelling, but in our currently disjointed system, it seems like a distant dream. Bush, in a keynote interview at the Digital Healthcare Summit in Boston, admits, “We’re sort of Star Wars 1 here in health care … So, ok, the market doesn’t work so well in health care, but what we want is a network.”

Moderator Brandon Hull challenged Bush a bit. At the conference, Bush shared a music video parody that ridiculed EMRs. Hull noted the video’s message that, “Doctors hate EMRs … The last I looked, you’re in the business of selling EMRs.” Bush agreed that what we currently have is far from what we want and pointed to the lack of a coordinated vision on the part of the government as a key factor.

He cited the rush to tie physicians and hospitals to electronic health record systems without supporting infrastructure as one of the reasons for the lack of interoperability. To get to his vision of a fully functioning software enterprise system, Bush recommends taking a hard look at our current situation. “With everything in life, the first thing that you want to do if you really want to live fully is to stare vividly and unflinchingly for a very long time at the awkward reality of your current situation and then you can look off to your right and see a beautiful world that you wish you were in.”

Considering the current tech challenges in health care, Bush takes a sympathetic stance on the plight of doctors. During the talk he shared the image of a painting that he takes inspiration from, called “The Doctor” by Sir Luke Fildes. In it, a pensive doctor sits at the bedside of an ill child. “This guy, to me, is on the edge of his humanity…” he shared. “And what I believe is that digital health represents the wicking away of the things … that don’t require this level of presence is the job of the cloud and is the job of technology.”

It’s a beautiful vision, but is it realistic or even attainable?

The brutal truth about health care today is that the pensive doctor now has a large computer screen between her and her ill patient. Bush admits that we’re far from the vision currently and admits that doctors’ documentation work has become “life-sapping.” His long-term vision, however, is to make this work automated and routinized, so that doctors can be more fully present for patients.

Bush notes with irony that currently 12 million faxes are sent between the IT systems of health care providers despite the overwhelming adoption of electronic health records throughout the health care system. Bush attributes the stimulus of the ACA with the wide but ineffective adoption of EMRs. Speaking of the stimulus, in his usual colorful manner, he said, “What did Keynes say? If you pay a 100 guys to dig a hole and another 100 to fill the hole, at least you get the ball rolling.” According to Bush, despite requiring the collection of meaningful use data, the government has built no infrastructure to actually receive and measure it. He went on to discuss how regulations just add additional complexity to the system, which when worked around, create “ridiculous absurdities” and additional bureaucratic drag.

Still, he feels there is plenty of room for innovation, which is reflected in the creation of athenahealth’s innovation arm, called MDP, or More Disruption Please. Through MDP, athenahealth provides investment and support to start-ups and entrepreneurs who share their connected health vision. “We think of health care as a few trillion dollar industry. It’s thousands of a couple of billion dollar markets, all masquerading as one thing … My thought with MDP is that what we need is thousands of companies with no cost of sale, no cost of implementation, that are very results oriented, maybe they almost morph between a vendor and a provider, and they kind of come together and focus on these thousands of industries and get a 10x return because you don’t have to put very much in and the cost of sale, of implementation, is so low because you have this backbone to plug into an app store, if you will, that you can start verticals.”

Besides improving care of individual patients with a powerful network of providers, Bush feels the health care Internet can also create a new opportunity to study diseases. Under our current system, it is difficult to get enough patients with certain diseases in one place in order to conduct a study with high enough power, but that could change with enhanced technology. He also sees an opportunity to better address population health, not just in those with chronic disease – which is a focus currently due to the high costs of care of these patients – but ultimately other groups of patients as well, and the ability to do this at scale.

One regulatory shift that Bush seems to favor is the emphasis on fee-for-value versus fee-for-service. He argues that risk-bearing creates a rich market with a large number of buyers and sellers, competitively innovating cheaper and better solutions. His hope, through MDP, is to help create this rich health care ecosystem. He asserts that it’s not athenahealth’s objective to build or be the storefront for all of these businesses, but rather to simply encourage their development.

This long-view of health care and investment in MDP places athenahealth ahead of the hundreds, if not thousands, of other EMR providers. It shouldn’t surprise anyone if someday the much-sought-after and elusive health care Internet is ultimately hosted on servers built by Jonathan Bush and athenahealth.

 

This article was originally published by Healthegy.

Walgreens: Investing in the Power of the Patient

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Thanks in part to Affordable Care Act reforms and the rise of digital health, patients now have more skin in the game, more health care tools at their disposal, and more information than ever before to take charge of their own health.

Dr. Harry Leider, CMO and Group VP of Walgreens, speaking on a panel at last week’s Digital Healthcare Innovation Summit in Boston, said health care providers must find a way to adapt to the schedules and demands of patients, who have more say over how their health care dollars – and their time – are spent.

“Traditional providers are learning that they [patients] are not willing to take a half-day off from work, figure out what to do with their kids, to get routine care,” he told the panelists. “People are busier, the information technology has made it easier to get solutions without having to spend a half-day somewhere.”

It’s no surprise, then, that pharmacy retailers are placing big bets on consumer-facing health care opportunities.

In the past few years, the pharmacy-services giant CVS Health has made big investments in this area, dropping tobacco sales, expanding its MinuteClinics, and also establishing a drug ad-herence program. Now with Walgreens’ recent announcement of its $9.4 billion acquisition of Rite Aid Pharmacies, it has effectively overtaken CVS to become the leader with 46.5% of the market to CVS’ 30.9% share.

But Walgreens is looking to get bigger on the back end as well. Also, just this week it announced an upgrade to their mobile app which improves its functionality and also expands their telehealth services to 25 states (previously available in only 5 states). Walgreens’ other health care investments hint at its level of commitment, including its partnership with controversial laboratory services company Theranos and a recent announcement that it has partnered with health information tech giant Epic to install that firm’s electronic health record software across all of its health care clinics.

Walgreens is banking on its huge presence to provide easy and convenient access to the next generation of health care consumers. “Everybody knows Walgreens,” Leider said. “We have 8,300 stores, 25,000 pharmacies, and over 1,000 nurse practitioners in our clinics.” He also emphasized that half of Walgreens are located in ethnically diverse areas, with a large number of especially high-risk populations, which gives them a unique opportunity to influence health care outcomes. “Take the average diabetic patient. Diabetes is an epidemic in our country, but especially among diverse populations. First of all, a diabetic, if they’re lucky, sees a primary care doctor two to three times a year. The average diabetic comes to our pharmacy counter 20 times a year. So the opportunity to provide systems that can solve problems is greater because of this.”

Walgreens has started a digitally supported Healthy Choices Program, which rewards consum-ers for walking, weighing themselves, logging blood pressure and blood glucose levels, commit-ting to smoking cessation, and setting other health goals. In addition, it offers digital health coaching, pharmacy checks, and even virtual doctor visits.

Roughly 800,000 people have signed up, Leider said. About 500,000, of those patients are sharing their personal health data with Walgreens. What the company has found thus far from its collection of these data is that engaged users (who are actively tracking their weight) lost an average of 3.3 pounds more than non-engaged users and 1 out of 6 lost more than 10 lbs. In addition, Walgreens found that its engaged users have overall healthier behaviors and better drug adherence.

Still, he’s not a blind advocate of digital health: “I don’t think digital health alone can solve the problems you’re talking about.” Leider insists that Walgreens is not trying to usurp the tradition-al establishment but rather be a resource to providers. “We really see ourselves as supporting traditional providers and adding value to the ecosystem. We’re not gearing ourselves up to do primary care,” he said. “So our strategy really is to provide a low-cost option for care and to partner with health systems and providers.”

Going forward, Dr. Leider would like to see a greater transition to value-based care. “Despite what everybody’s saying, most providers are still trying to keep the beds full and have the most number of visits. So, for all this tech to be funded and sustainable, it’s got to be the right envi-ronment to really reward people for staying well.”

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This article was originally published at www.digitalhealthcaresummit.com.  

Cool Startup: RubiconMD

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Primary care practice stands on the precipice of radical transformation as emphasis shifts from offering volume-based to value-based care. Look no further than the recent Supreme Court ruling to see that the ACA and its mission are becoming further cemented into the U.S. healthcare system. The goals are lofty: higher quality and greater access to healthcare at a lower cost. For most, it’s hard to imagine what this healthcare landscape will look like in the future.

But Gil Addo, the CEO and founder of the NYC- and Boston-based healthcare startup RubiconMD, seems to know. His novel vision of the future involves shaking up the traditional model of primary and specialty care practice in medicine.

A Yale and Harvard Business School graduate, Addo’s experience as a consultant and in commercializing innovation has included industry stints at both large and small tech and biotech companies. In early 2013 he met co-founders Dr. Julien Pham, a physician formerly on faculty at Harvard Medical School, and Carlos Reines, another Harvard MBA.

As of December 2014, they have raised over $1.4 million funding and support from major investors, including athenahealth and Waterline Ventures.

We sat down with Addo recently to talk about this innovative company and discuss his plans for the future.

Tell us about what you do at RubiconMD.

RubiconMD is meant to enhance access and bring appropriate specialist expertise into the primary care setting. The patients will see their primary care providers and whatever the issue is–if it is outside the PCP’s expertise and results in a referral—the physician can upload any relevant information, such as images, labs, and studies, and ask questions. We figure out who the most appropriate specialist is and then route the case to them so that they can respond within a few hours.

That’s the crux of the entire interaction. It’s a clinician-to-clinician electronic consult.

How did you get the inspiration to start RubiconMD?

I was very interested in this problem of enhancing access and wanted to find a way to solve it. I had a personal experience that motivated me to take this on. I had a grandmother who had to travel thousands of miles to Boston for treatment of a brain tumor, and then back and forth for all the follow-up. Why couldn’t her local provider oversee her care with appropriate support? There had to be a better way.

I traveled to India and looked at different healthcare delivery models and found that better way. There they have an extreme version of what you see everywhere: the appropriate expertise is in a concentrated area and people are everywhere else, so they bring the appropriate expertise into community health centers.

I started iterating on that model and borrowed things from other settings until I arrived at a solution that fit the U.S. healthcare market. RubiconMD allows increased access to the right specialist and brings that expertise into the primary care setting, to the front line.

How did you figure out if this might be something that primary care physicians would actually be interested in?

Once we figured out that the idea made sense at a system level, we had to figure out if this was a solution that physicians would use. Julien brought his clinical expertise and introduced the idea of “curbside” interaction, an informal and natural way that physicians interact with each other. We were able to validate the model on a small scale and see that physicians would actually use it and find value.

We ran a larger scale pilot to see if this would save people money. We used two large clinics with a panel of specialists and ran it across 15 or so specialties. The findings have been remarkably consistent.

  • In a third of the time, this support avoids a specialist visit. This has been consistent across all deployments and different populations.
  • Another third of the time this process improves the referral. You’re able, even though you’re referring, to send along the appropriate labs and studies and waste less time. And you make sure the patient goes to the right specialist.
  • For the remaining third of the time, it’s peace of mind. It validates what you were going to do.

The cost savings is from improving care outcomes and avoiding duplicate and inefficient use of resources. Almost $300/per opinion is saved, aside from other benefits such us reducing wait time and avoiding ancillary costs to patients.

Is this billable to insurance?

It is not. Right now, we work with value-based organizations incented to provide high quality primary care in the most affordable way possible who see this as a way to extend their capabilities, provide better and more timely care in the primary care setting and avoid unnecessary services.

Payers show interest, as this is a great tool to enhance outcomes and reduce costs while improving patient satisfaction.

What are the challenges that you’re having? 

No shortage of challenges. We focus on the sphere of healthcare that is value-based and incented to provide high quality care at the lowest cost. But U.S. healthcare still has a very large fee-for-service component and the biggest challenge is that we’re dealing with so many groups fighting themselves. It’s a system in transition. We’re trying to bring this into that environment and show them how we help them transition. It’s tough but enough of the market has moved and enough changes in primary care have happened that we have been able to gain momentum quickly.

What are your next goals, short-term and long-term?

Short term, we want to continue better servicing our customers, provide better tools to meet their needs and fit even better into workflow. We’re obsessed with enhancing workflow and not making additional work — providing a tool that syncs with the way physicians want to practice medicine.

Long term, we’re focused on the idea of democratizing medical expertise. As our longer-term vision, we want this to be the default. We want people to think of RubiconMD as the way to get high quality consults more efficiently and locally so that there’s no barrier for clinical expertise.

This article was originally published at MedTechBoston.com.

Electronic Health Records: Opportunities

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As discussed in the previous article in this series, the broad adoption of electronic health records (EHRs) has presented healthcare professionals with numerous challenges. It’s not surprising that many of us are left wondering: Will all of this effort to rapidly adopt EHRs even be worth it in the end?

Where We Are Now

To better understand this, it’s helpful to first take a closer look at the current state of the U.S. healthcare system. In 2000, the Institute of Medicine released their landmark report, To Err is Human, which exposed the alarming number of deaths that occur as a result of medical errors in the U.S. This was a big shock to many who assumed that the American healthcare system was the best in the world. To add insult to injury, we also discovered around that same time that healthcare costs were skyrocketing – in fact, they had doubled from 1993 to 2004.

According to the Commonwealth Fund, the United States today has the most expensive healthcare system in the world, spending about $8,500 per capita, or nearly 18% of our GDP, while also consistently ranking dead last in overall performance and quality compared to all other industrialized nations. One can’t help but wonder: What are other countries doing that we’re not? Well, two things in particular stand out when we compare our healthcare system to theirs: 1. A lack of universal healthcare coverage; and 2. A lack of high-functioning, fully-integrated health information systems. It turns out that our international counterparts have surpassed us when it comes to providing high quality, affordable, and accessible healthcare. One of the key elements of their success has been harnessing health IT.

Opportunities to Consider

Considering all of this, it’s no surprise that we have had bipartisan support for the expansion of EHRs from both Presidents Bush and Obama and that we continue to invest in creating a fully interoperable, nationwide network for health information. If EHRs can be harnessed properly, they promise to deliver lowered healthcare costs, improved quality, increased access, and improved population health. Let’s take another look at those challenges presented in the last part of this series. Where are the opportunities in these challenges?

1. Cost

Despite the high costs of implementing new EHR systems, there are also numerous studies that report that high-functioning EHR systems can help to decrease costs in the long run. One study found a 12.9 to 14.7% reduction of duplicative testing with the use of computerized provider order entry (CPOE) and clinical decision support (CDS) in an outpatient setting. Overhead costs may also be decreased through the reduction of chart pulls and from reduced paper, supplies, and storage costs, as well as via decreased transcription costs. Efficiencies can also be gained in billing processes with improved and complete documentation, improvements in the charge and capture process, and through decreases in billing errors. A study from Massachusetts found that paid malpractice claims may also be minimized with use of EHRs vs. paper records (6.1% vs. 10.8% paid claims).

It remains to be seen if EHR-induced savings will be favorable versus the cost expenditures required to operate them. But these studies show that there’s reason to be hopeful.

2. Quality & Communication

Investing in a high-quality EHR system has also been shown, in some studies, to result in higher overall quality, improvements in safety, and decreases in delayed medical decision-making. A study of hospitals in Florida found that those with greater investments in health information technology scored higher in quality measures. A similar study found that those hospitals with greater investments had lower patient complications and lower mortality rates as well. Other research has demonstrated that high-quality EHR systems improved prescribing patterns, too. In these ways, EHRs may support improved outcomes and thereby reduce malpractice and liability risks.

Highly interoperable EHR systems have also been credited with improving the communication and coordination of care between providers, and with decreasing delays in medical decision-making that can result from having to wait for the transfer of medical records. A strong health IT system can also enhance communication between providers and patients and help to foster increased patient engagement through the use of applications such as patient portals and interfaces with radiology, laboratory, and medical devices. Patients may be more apt to become actively involved in managing their health and participating in shared decision-making as a result of having easier access to their health information. 

3. Access 

Another advantage of EHRs is that they can help to provide convenient and timely access to a patient’s health record. We’re still a far way away from a fully transparent nationwide (or global) healthcare network, but these advances are coming. In addition, as the telehealth and mHealth market grows, and as we see better integration of other platforms with EHRs, we will likely see a huge revolution in access to personal health information. This need is especially urgent in light of the dire shortage of primary care physicians. Telehealth capabilities of EHRs may very well be the solution to providing access to medical care for patients in underserved or remote regions.

4. Population Health

As we succeed in integrating systems and improving interoperability, we will have the ability to aggregate huge amounts of health data for entire populations of patients. This “big data” can be used to conduct population health research, which can help identify patterns such as risk factors for diseases. With this, physicians will be better able to recommend preventative measures and evidence-based best practices. This information can also be harnessed to change practice patterns and hopefully, to affect positive healthcare outcomes on a broader scale. EHRs can also help to enhance reporting capabilities, which may help identify potentially dangerous outbreaks or treatment-related risks quickly, so that they can be managed in a more timely and effective manner.

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The Bottom Line

EHRs hold a great deal of promise to truly transform our ailing healthcare system. How well we succeed will depend in large part on how we can overcome and manage key challenges affecting cost, interoperability, safety, and patient-centered care. It remains to be seen if the cost-to-benefit will be ultimately favorable, but these preliminary findings and evidence of international success give us reasons to be hopeful.

This article was originally published on MedTech Boston.