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Innovations in Care

Jonathan Bush on founding Zus Health, lessons from athenahealth and hospital cafeteria food

Gabriel Perna | July 28, 2021

Three years after he was forced out of athenahealth, Jonathan Bush founded health IT startup Zus Health. Not surprisingly, he’s as animated and motivated as ever.   

The veteran health IT CEO left athenahealth in 2018 amid allegations including domestic abuse and sexual harassment as well as a hostile challenge from activist investor Elliott Management Corporation. A year after he departed, Bush joined Firefly Health as executive chairman and in June of this year, he founded Zus Health, which aims to create an open development platform for digital health companies backed by a shared data record. Zus closed an opening $34 million funding round led by Andreessen Horowitz.  

Bush, who co-founded athenahealth in 1997 with Todd Park, says the idea of a shared record came to both of them early in the company’s history. However, athenahealth found success in other avenues and never saw a need for that kind of platform during his time there. In the years since he has left, digital health companies have emerged left and right, giving him the hypothetical market for companies that could benefit from a shared data record. At the same time, the health care landscape experienced, as Bush calls it, “a successful, global beta production of virtual care.”  

All told, it led him to founding Zus Health. In this wide-ranging interview with Health Evolution, Bush discusses leaving athenahealth, why incumbent health care organizations are missing the mark on patient experience with surveys that ask about cafeteria food, and more.  

What is your vision for building Zus Health?  

When Todd and I started athenahealth, or rather when we turned to its current business model, we had an idea that we were going to create a health care extension on the internet. We were going to do that by taking doctors and getting them to [document] their daily life through what at the time would have been the [industry’s] first industrial strength internet native platform. We thought that would lead to a lot more coordination of care. We never really got to a shared record and there were a million reasons why. For one, it was really hard to re-platform our technology. Two, a lot of the providers on our platform didn’t want that in their heart of hearts. I mean they said they wanted it but many of them live on the monopoly pricing they have for their diagnostics. When athenahealth got sold and my workbench was wiped clean, part of what I spent some time thinking about was what would make there be a common record?   

Zus is the culmination of this idea that there is a new class of company that selfishly benefits from a shared data record. These highly targeted digital health solutions, where you have one guy doing alcohol treatment, another guy is doing primary care, and another guy is only doing whatever are very narrow. In that world, you can build something for them but what do they need? They don’t want an EMR, they want to build their own EMR. They don’t want to bill a claim ever in their life. What’s the business model? The idea of a software developer kit and a set of platform services that would allow other people to build their own billing platforms is what emerged. Hopefully, what happens is that goal of a shared record gets met here.  

All the money pouring into digital health presents considerable opportunities, so who are the companies Zus is targeting?  

Companies that profit from coordinated care, not companies whose CMIOs give speeches about coordinated care. The companies that actually profit from coordinated care that have in-built technology capabilities. Those are the target audiences. If you’re trying to create a monopoly, coordinated care outside of your walls may be bad, whereas if you have a point solution, you need coordination to prosper. That’s how I’m segmenting the market.   

Our initial builders like CityBlock, Firefly, and Oshi, are selling either a global bundle across a lot of providers, whole-life risk, or just flat out care coordination as a service. Of course, they profit from coordinated care. None of them have their own imaging department or whatever. It’s that kind of company. Initially, I thought they’d be many years of waiting for that kind of company to emerge but over COVID, there were suddenly thousands of entrants and tens of billions of dollars that have gone into these companies. I didn’t quite expect a global pandemic and billions of dollars all at once, but I ain’t complaining.  

What have you seen during COVID that made you realize the timing was right for Zus?   

A successful global beta production of virtual care is what I saw. How important is network development? Network development is defined as building a Noah’s Ark in every single city that you want to [service patients]. Well, what if you could just have one cardiologist for the whole country that you could instantly beam in? What if your network development became total technological integration and total collaboration? That’s kind of fun for the network developer but also for the specialist/expert. I can see some people quietly hoping this goes away. You’re building out a new network, going into a new market and you need no specialist, and you don’t have to do a deal with the troll under the bridge at the local medical center. That’s interesting to me.  

Looking back, I spent a hilarious amount of time getting the setting right for working on this complicated, single monolithic project. It was fun, but it was not modern. The pandemic cleaned up that thinking for people. We all instantly, with no warning, had to work 100 percent remotely for a while. It cleaned out a lot in-person waste.

Jonathan Bush, Zus Health

How do you look at where we are as an industry in terms of disruption and non-traditional health care entities taking a piece of the pie?   

This is a metaphor for someone patting themselves on the back for their patient survey scores. What the hell is a patient survey score? Among the cafeteria foods you have eaten in the last year, how was this cafeteria? ‘I guess it was good. The aluminum, steamed plate of lasagna tasted fine. I am not comparing it to an Italian Bistro though.’ In health care, it’s like that. When compared to other hospitals, it’s fine and the organization complies with the various rules that they need to comply with. But that doesn’t mean the patient thought their experience was an expression of the organization’s humanity. It doesn’t mean they got more emotional comfort than they could get from other experiences in their lives. That’s why you need someone outside of this ecosystem and echo chamber to show up with a different idea. Someone who would never dream of paying a survey company for a 35-page mailed paper questionnaire. There’s nothing wrong with paying a patient survey company, but it points out the problem of evolution as your primary means of progress. Evolution is good, but evolution aided by disruption is better.   

What lessons are you taking from athena that you’d like to bring here? What do you want to do better?   

I loved athenahealth. Every bit of it, even that miserable last year when I was being hounded by Elliot. It was sort of an honor to be burned on fire in the village green. I was able to look back on that, laugh and realize it’s just a job. And the company seems to continue to do well, people have jobs they like. I had the joy of a great experience there.   

But my approach at athenahealth was monolithic. My own continued leadership was monolithic. The average CEO is in their job around 36 months or something. I was there for 22 years. Everything in athenahealth was written in Perl, we didn’t allow new languages. Very little of it was containerized. It was a monolithic code set, so it’s very hard to write new things. You can’t find all the things it’s interconnected to over the 22 years because it’s being frantically coded at top speed. That had cultural implications. We pushed people to work at work. You needed special permission and have certain jobs to not to be in the office with your teams every day. You had a monolithic culture. Our campuses were very important. Looking back, I spent a hilarious amount of time getting the setting right for working on this complicated, single monolithic project. It was fun, but it was not modern. The pandemic cleaned up that thinking for people. We all instantly, with no warning, had to work 100 percent remotely for a while. It cleaned out a lot in-person waste.   

For me, Zus is extremely containerized. There are three products, each product doesn’t even need to use the other products to function. The code is containerized. I require people to meet once every month with someone and every other month as a team. Other than that, you’re good to go. You can live anywhere and work any style you’d like. Your code can be polyglot. You can write anything you want, as long as it marries up to this API. You’re not coding against screens that a hospital, doctor or a lab will see. You’re coding up to APIs that engineers will do all kinds of things to that you have no idea what they’ll do. You’re building for builders. It’s the opposite feel. We don’t have a headquarters. We rent desks at FireFly. We are really focused on this thing being an extremely agile, nimble, containerized set of tools. We are absolutely committed to selling commercial alternatives to everything we build within our developer kit. It’s going to be a massively open company in every respect. That’s opposite of what I did at athenahealth. I’m not sorry for what I did at athena. It worked for a long time. But because of the over-integration and monolithic nature of athena, and the desire for a new business challenge, I’m going the other way.   

Where do you envision the company will be in one year? Five years?  

In a year, I want 30 companies building patient relationship management apps and services on the platform, reading, and writing off common data records, occasionally reading and writing off identical data records, maybe doing some EMR work, and maybe starting to open up the sharing doors. I’d love to see two companies say, “You collect that kind of data when you treat people and I collect this kind of data when I treat people, do you mind if I peak at your data when I’m treating the same people?” If they each open their little door, that would be amazing. I don’t know if we’ll get there in a year, but let me say this, by the time I raise money again, I want those things to be true. And for long-term goals, I want to retire before being fired. That’s a biggie. I want to leave Zus without going feet first.   

About the Author

Gabriel Perna, Senior Manager, Digital Content

Gabriel Perna is the Senior Manager of Digital Content at Health Evolution. He brings 10+ years of experience in covering the intersection of health care and business. Previously, he was at Chief Executive, Physicians Practice and Healthcare Informatics. You can reach him via email at gabrielp@healthevolution.com or on Twitter at @GabrielSPerna