The Difficulty of Technology Disruption in Healthcare

The new book by athenahealth's Jonathan Bush offers few ways out of the current healthcare mess, despite the importance of technological fixes. But liberated data is a bright spot.

"My fondest wish, my highest hope, is to inspire a small clan of crazy ones in every substrata of the healthcare system. A small strata of crazy medical school deans, a small strata of crazy health system CEOs, a small strata of community hospital CEOs, a small strata of crazy primary care docs. Each one of them says, I am going to be the guy who marches the wrong way. I am going to be the guy who stops protecting my flank and starts attacking her flank. And the great news is, I don't need many of them, because the point is, we've got about 50% excess capacity in our system, so frankly, if everyone did it, it wouldn't work."

So says Jonathan Bush, CEO and co-founder of the prominent ambulatory EHR software maker athenahealth. In my Q&A with him last week, Bush took aim at complacent large healthcare organizations who expose their flank to disruptors, but fail to use technology effectively to expose others' flanks, instead relying on an older generation of technology to lock in physicians and patients.

But to some degree, Bush may be attacking a straw man. His recently published book, Where Does It Hurt? An Entrepreneur's Guide to Fixing Health Care (Portfolio/Penguin), doesn't mention the many interoperability initiatives already under way, from Healtheway to the Direct Project to the newest one, HL7's Fast Healthcare Interoperability Resources.

Now I admit, it can be extremely difficult to write a book about the ever-shifting landscape of information technology. I should know—I tried to write one for several years. It's like trying to nail Jell-O to a wall. The technology flavor-of-the-month may be totally irrelevant by the time the book comes out.

For some reason, Bush fails to mention athenahealth's own participation in the CommonWell Health Alliance. He deplores the practice of health systems withholding patient data from each other and from patients, to improve care coordination, but misses an opportunity to lay out specific proposals to kick-start health information exchange.

For CIOs and other healthcare leaders looking for takeaways from this book—from the vendor who most pointedly offers physicians an escape route from assimilation by hospital systems dominated by Epic—they get a few too many polemics and too few tech tips they can use.

A prime example is Bush's suggestion that a way to fix spiraling healthcare costs is to have terminally ill patients share in the savings achieved if they should refuse care, with their heirs benefitting. The Wall Street Journal book reviewers termed this suggestion "disquieting." I'm sure other critics will use stronger words.

Bush says he could have written another whole book about the problems caused by healthcare payers. "I don't rail against the software problems in insurance companies, because I've basically written off the insurance companies for dead, because dead and regulated within an inch of your life aren't that different," he says.

In our conversation, Bush shared an interesting story of athenahealth's own struggle to obtain claims data from Medicare.

"We've been working with Medicare for four years now to release data," Bush says. "We're a covered entity under HIPAA. We have access to millions and millions of claims. And yet Medicare won't give us back the claims data for the patients our doctors serve, which is astonishing."

Bush and I agree that the prospect of more and more such liberated data is one bright spot in healthcare's current predicament.

"All of that stuff is finally becoming visible, and as more and more data becomes available, and as the possibility to profit from doing better care grows, you'll see the possibility of product management," Bush says. "You'll see a hospital say, 'Well, I don't care if there's a third-party payment for this. I'm going to do it anyway, because I'm going to get so much bonus money on the back end from the reduced ED admissions that it's going to be worth it to me.' That kind of ROI-based product management is what's primarily missing from hospital and downstream medical care in the country."

One question that inevitably rises out of the book is whether Bush's own company will lead the way to the innovations so necessary to fix healthcare. Despite a general recent dip in tech stock prices, Wall Street seems enamored of athenahealth's prospects to provide truly disruptive change. Its cloud-based EHR software is a few generations ahead of your average EHR in terms of the kind of flexibility software requires to keep up with ever-changing demands of the healthcare business.

But due to the tremendous regulation healthcare faces, the cost a technology vendor such as athenahealth pays to stay a player in the game is staggeringly high and a real barrier to entry to future software innovators. "We've easily blown $50 to $100 million worth of R&D and product work on rules that have been evaporated at the final hour," Bush says.

I think it fortunate for our industry that Wall Street remains willing to pour even more money into software to solve healthcare's woes, despite years of setbacks in adoption, regulation, and dominant market players.

If and when Wall Street gives up on healthcare IT innovation, we may be in a situation far more troubled even than Bush describes in his book.