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Scaling is Hard. Case Study: athenahealth

By Jeff Bussgang

There are many companies that are competing to be the “operating system” for small businesses. The theory is that with the advent of the cloud in the digital age, small businesses can leverage a suite of services from a technology vendor to manage all aspects of their work – from payments to record-keeping to marketing to customer communications.  Among those competing for this vision are PayPal/eBay, Square and Groupon, with each struggling to pull together pieces of the equation and, importantly, reach the small business in a cost-efficient manner at scale.

One company in Watertown, Massachusetts has been executing on this vision for over a decade with a winning approach for one vertical slice of the small business market:  physicians.  Although this is not typically how athenahealth is described, it is one way to describe what they are doing that mainstream members of the technology community might understand.  I have found it pretty amazing that so few people in the tech community know their story or understand the scale and scope of what they have achieved.  That is why I’ve chosen athenahealth for the third in my series on scaling (following Akamai and TripAdvisor).

Founding Story:  A Pivot

Athenahealth version 1.0 was a complete failure.  The company was originally founded in 1997 by Jonathan Bush (1st cousin of George W.) and Todd Park, a pair of Booz Allen consultants, as a physician practice management company for obstetrics.

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Are Organics More Nutritious? Again? Sigh.

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By Marion Nestle

The latest study arguing that organics are not more nutritious than conventionally grown crops once again makes big-time news.

The last time I wrote about a study like this, I posted the British newspaper headlines.

Never mind the media hype. Here’s what the authors conclude:

The published literature lacks strong evidence that organic foods are significantly more nutritious than conventional foods. Consumption of organic foods may reduce exposure to pesticide residues and antibiotic-resistant bacteria.

Isn’t reducing exposure to pesticides and antibiotic use precisely what organic production is supposed to do?
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Economics and Health Systems

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By Conor Green & Chris Hoffmann

Two of the largest healthcare systems in the Twin Cities have announced plans to merge – and if approved it will created the second largest hospital system in Minnesota in terms of revenue (Mayo Clinic is first).

For those non-Midwesterners – the geographical environs of the Twin Cities Metro area comprise a 50 mile circumference anchored by Minneapolis to the west and St. Paul to the east. At a high level, this move essentially links West (Park Nicollet) and East (HealthPartners) and according to news releases from both organizations, the combined health system will include more than 20,000 employees and 1,500 multispecialty physicians. However, there is a more compelling angle to this story.

On the surface the motivation for this move could be primarily economic: The average operating margin for a U.S. hospital is 2.5% — tough financial sledding in a disrupted and crowded market. Overly simplified, the economics of a hospital requires keeping beds full (aka “heads in beds”) … and as hospitals today strive to better align with physicians in order to get more than their fair share of referrals, a range of new business models and ways to engage consumers are emerging in the marketplace.
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Getting the Right Benchmarks For Stroke Care

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By ASHISH JHA, MD

Late last week, thanks to Liz Kowalczyk (@globeLizK) of the Boston Globe, I discovered the statewide report on quality of stroke care in Massachusetts.  It’s a plain document, mostly in black and white, much of what you might expect from a state government report.  Yet, this 4-page document is a reminder of how we have come to accept mediocrity as the standard in our healthcare delivery system.

The report is about 1,082 men and women in Massachusetts unfortunate enough to have a stroke but lucky (or vigilant) enough to get to one of the 69 Massachusetts hospitals designated as Primary Stroke Service (PSS) in a timely fashion. Indeed, all these patients arrived within 2 hours of onset of symptoms and none had a contradiction to IV-tPA, a powerful “clot busting” drug that has been known to dramatically improve outcomes in patients with ischemic stroke, a condition in which a blood clot is cutting off blood supply to the brain.  For many patient-ts, t-PA is the difference between living a highly functional life versus being debilitated and spending the rest of their lives in a nursing home.  There are very few things we do in medicine where minutes count – and tPA for stroke is one of them.

So what does this report tell us?  That during 2009-2010, patients who showed up to the ER in time to get this life-altering drug received in 83.3% of the time.  Most of us who study “quality of care” look at that number and think – well, that’s pretty good.  It surely could have been worse.

Pretty good?  Could have been worse?  Take a step back for a moment:  if your parent or spouse was having a stroke (horrible clot lodged in brain, killing brain cells by the minute) – you recognized it right away, called 911, and got your loved one to a Primary Stroke Service hospital in a fabulously short period of time, are you happy with a 1 in 5 chance that they won’t get the one life-altering drug we know works?  Only 1 in 5 chance that they might spend their life in a nursing home instead of coming home?  Is “pretty good” good enough for your loved one?

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What Business Can Learn From Cleveland Clinic: How To Report Quality To The Public

By David Whelan

This summer I spent some time exploring how big teaching hospitals publicly report clinical outcomes to the public. For a given set of patients, how many live or die? And with what complications?

Patients can rarely find this information before getting elective surgery, or when deciding to commit to a given institution for a long-term course of treatment.

The problem is that right now there are few short-term incentives for hospitals to be transparent  to the public. Patients are used to finding care based on proximity, word-of-mouth, and referrals from trusted physicians. (None of these are bad methods, by the way.)

Meanwhile insurers and public programs rarely pay for better outcomes, so they do not build networks that steer patients to quality. Paternalism pervades the entire system, where insurers and providers alike do not trust patients to shop for the best care.

Thus it is only the most long-term focused institutions that decide to become radically transparent. And there’s one that stands out above the rest: Cleveland Clinic.

The Ohio institution is already known for excellent care, especially in cardiology, for being a “well-oiled machine”, and for being an economic bright spot in the otherwise dreary environs of Cuyahoga County. (Sorry, as  Pittsburgher it’s hard for me to say nice things about the Mistake By The Lake.)

But something else Cleveland Clinic should be known for is its public outcomes reporting. Every year since at least 2005 Cleveland Clinic has published Outcomes Books on its Web site. For each clinical category it releases data on mortality, complication rates, and patient satisfaction. It also mails paper copies of these books to specialists around the country as a kind of transparency-marketing. No other hospital system comes close to reporting this level of detail about the quality of its care.

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Burnout

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By ROB LAMBERTS, MD

It happened again.  I was talking to a particularly sick patient recently who related another bad experience with a specialist.

“He came in and started spouting that he was busy saving someone’s life in the ER, and then he didn’t listen to what I had to say,” she told me.  ”I know that he’s a good doctor and all, but he was a real jerk!”

This was a specialist that I hold in particular high esteem for his medical skill, so I was a little surprised and told her so.

“I think he holds himself in pretty high esteem, if you ask me,” she replied, still angry.

“Yes,” I agreed, “he probably does.  It’s kind of hard to find a doctor who doesn’t.”

She laughed and we went on to figure out her plan.

This encounter made me wonder: was this behavior typical of this physician (something I’ve never heard about from him), or was there something else going on?  I thought about the recent study which showed doctors are significantly more likely than people of other professions to suffer from burn-out.

Compared with a probability-based sample of 3442 working US adults, physicians were more likely to have symptoms of burnout (37.9% vs 27.8%) and to be dissatisfied with work-life balance (40.2% vs 23.2%) (P < .001 for both).

This is consistent with other data I’ve seen indicating higher rates of depression, alcoholism, and suicide for physicians compared to the general public.  On first glance it would seem that physicians would have lower rates of problems associated with self-esteem, as the medical profession is still held in high esteem by the public, is full of opportunities to “do good” for others, and (in my experience) is one in which people are quick to express their appreciation for simply doing the job as it should be done.  Yet this study not only showed burn-out, but a feeling of self-doubt few would associate with my profession.

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Building a Medical Practice: Does Government Help or Hinder?

By David M. Mokotoff, MD

Over 30 years ago, I began a cardiology group practice in St. Petersburg, Florida, Bay Area Heart Center. I invested $30,000––all of my savings at the time, and worked 90-110 hours per week for three years before I hired a partner. Since then the practice has grown to about 50 employees, including twelve physicians. I was taken aback by President Obama’s recent remark, “If you’ve got a business — you didn’t build that.  Somebody else made that happen.”

Did I have help building this business? Yes. I have been graced with fine physician-partners, nurses, physician assistants, secretaries, medical assistants, and a remarkably efficient and dedicated administrative staff. But in all due respect, Mr. President, I must disagree with you.  I did build my business, and nobody else made it happen. , along every step of the way, the federal government has been more of an impediment to the growth of my business than a facilitator.

From Medicare dictating to me how much I can charge a patient for my services, to OSHA requirements against using lip balm in “patient-care” areas; federal rules, regulations, and bureaucracies have heaped increasing administrative costs on my business without one iota of improvement in patient care. Now with the imminent implementation of “Obama Care” dangling over us, the outlook is even direr.

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Demo: Healthline Launches BodyMaps for the iPad

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By Matthew Holt

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Health information and education company Healthline Networks launched the BodyMaps iPad application today. BodyMaps, which displays rotatable high-resolution 3D illustrations of human anatomical structures, was created with GE Healthymagination in partnership with Visible Productions. Here you’ll see Senior Director of Product Management at Healthline John Emerson demo the app on his iPad, and CEO West Shell talks about his own recent experience using BodyMaps at his orthopedic surgeon’s office.

Refocusing Long-Term Care on People: The Three I’s  

By Frank Spinelli

Both participants and caregivers in long-term care programs face a myriad of difficulties. Participants with long-term services and supports needs often have many health issues, meaning they are in constant transition between care environments and providers with their needs ever-evolving. As a result of visits to a number of doctors on a regular basis and the number of providers who support them, the participant’s information lives in multiple locations. This can lead to discrepancies between providers and the participant having to constantly provide the same information.

Caregivers, especially family members, are also facing great challenges. It’s a full-time job to care for someone in the home – it takes nearly 40 hours a week – and searching for a trusted service provider to take over can be another job in and of itself.

The root of the problem is that many long-term care programs are focused on the providers and not necessarily the people – those receiving the services and those providing them. Often, no one has the full picture of the participant’s health, which can lead to suboptimal care. An ideal situation is for everyone involved with the participant to be up-to-date and have a full-picture of their health and well-being at all times. When they are, services can be administered effectively with less risk for everyone involved.

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