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Edited Transcript of ATHN presentation 8-Mar-17 2:15pm GMT

Thomson Reuters StreetEvents

athenahealth Inc at Raymond James Institutional Investors Conference

Orlando Apr 10, 2018 (Thomson StreetEvents) -- Edited Transcript of athenahealth Inc presentation Wednesday, March 8, 2017 at 2:15:00pm GMT

TEXT version of Transcript

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Corporate Participants

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* Jonathan Bush

athenahealth, Inc. - Chairman, CEO, President

* Karl Stubelis

athenahealth, Inc. - SVP, CFO

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Conference Call Participants

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* Nick Jansen

Raymond James & Associates, Inc. - Analyst

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Presentation

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Nick Jansen, Raymond James & Associates, Inc. - Analyst [1]

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Good morning. My name is Nick Jansen. I'm the healthcare IT analyst here at Raymond James. We are very pleased to have the management team of athenahealth -- Jonathan Bush, CEO; Karl Stubelis, CFO; and the IR team, Dana and Kevin, in the audience. For those of you who aren't aware of athena, we will be just asking kind of fireside here, so we're going to start off with a quick maybe two-minute overview of a generalist audience of what athena is, where they are today in the marketplace and then we'll kind of go into some more of the deep type of questions.

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Jonathan Bush, athenahealth, Inc. - Chairman, CEO, President [2]

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athenahealth aspires to be the healthcare Internet, to get a chunk of the Internet and make it safe enough, secure enough, connected enough to the off-line world that it serves as a platform for providers and patients and emerging digital health providers to come to. We do that by offering a set of business services, activities that doctors hate and suck at -- billing, medical records, patient communications, care coordination -- on this platform. And it is a replacement to the traditional enterprise software products that dominate healthcare today. We are up to about 12% of all ambulatory medicine. Organically, we've been growing about 30-some% a year on average since the beginning. Right now, we are kind of in the 20s% as doctors have a little bit of a post-sugar high low from the eight years of the High Tech Act, etc.

Emerging for us are two new businesses. Our network service division has a mobile app called Epocrates, which has about half the doctors in the United States, and we are trying to basically turned that into a universal remote so that you can basically, regardless of what EMR your hospital is on, you can stay on our network and just connect in at a population health service which is basically helping those same networks manage risk contracts and identify patients that are slipping out of care and recruit some back into care. And the other emerging services are in patient care, so we are almost all ambulatory up until now.

We have entered the inpatient space with the same network, largely the same services, but for the lab, operating room beds, etc., of the hospital. We are starting at the low end, just as we did with doctors, and moving our way up. We are at about 100 hospitals 50 beds and below, and our primary constraint there is just making sure we don't oversell and then underserve because it's a new service set.

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Nick Jansen, Raymond James & Associates, Inc. - Analyst [3]

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Great. So speaking on that post-sugar high High Tech dynamic, the industry was propped up on pre-government stimulus. And as a result, you saw a wave of adoption, and now it's all replacement activity. So where --

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Jonathan Bush, athenahealth, Inc. - Chairman, CEO, President [4]

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I think it was more like of a wave of hot dog eating contests at gunpoint. They are all sick to their stomach. All of these systems that they've bought don't work. They are miserable. We are still selling huge whatever it was last year, more than we sold the first 15 years of athena combined in one year despite this low. And it was related to the fact that everything they were forced to buy they had already looked at before Obama and said it wasn't a good idea and passed on it, and then all of a sudden, they said, look, we'll give you -- the government said we'll give you $39 billion if you buy it, and we'll cut your rates by at least 2% and maybe more at the discretion of the Secretary if you don't. So they all rumbled down in this sort of panic thing, and people -- my friends say these are crocodile tears, Bush, you've got part of the lift along with everybody else. And I say no, they are real tears and they hurt, because basically the government drove all of the elk to one watering hole. And just because I am an elk hunter and I've got a lot of elk doesn't mean I'm happy because 100 drunks with Walmart rifles also got elks that I can now not get, or I have to wait until maybe elks grow up. So I am mad, and it's real. And the elk analogy may be a stretch, but I hope you got that.

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Nick Jansen, Raymond James & Associates, Inc. - Analyst [5]

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Part of the strategy this year is to take an additional FTE out of the business that drives cost savings and (multiple speakers)

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Jonathan Bush, athenahealth, Inc. - Chairman, CEO, President [6]

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That's right. So the core services, that original -- the 93,000 providers that we do their billing, patient communication, medical records, the primary product feature focus for the last six years to the tune of literally 100 R&D years per year inside of athena has been complying with every toccata scheme that comes out of Washington. So there's something called MIPS, there's something on MACRA, there's something called PQRS, there's something called High Tech. All of these are different reporting requirements laid upon doctors and health systems that affect their payment for Medicare and Medicaid. And we won the game in that we got all of our doctors through all of these programs at a rate that no other software-based company even knows if they did, but since the government receives these reports, they know that less than half of the installed base of the legacy companies were able to do it, and we were well over 95%. But all of that work was hard work at basically commoditizing ourselves, making a set of features and functions that the government made up in their product management glory and that we mapped to. And they are not, suffice to say, they are not remotely what our agile product management team would have developed with AB tests of the user base. And so those years took our eye off of what we know to be the driver of physician behavior, and increasingly it will be of hospital system behavior, which is cash, short cash. I am overwhelmed by complexity and distraction, and I need cash. And I would like to see more of my -- if you give me, that then as a second interest, I would like to be a doctor with more of my time than half.

So, today doctors are apoplectic every day. There is this grumbling malaise. If you look at the tweets from the AMA or if you go to their conferences, you can't believe -- you would think they were chattel slaves or domestic servants being told to polish under threat of whipping, but they are not. But they are -- they are -- they have genuine, I think, right to take umbrage at the fact that 50% of their day is truly not by any measure affecting the clinical quality of their care. For example, all of the programs that I just described, MIPS (inaudible), the meaningful use program, not one stitch of data was ever presented to the government. So, all of these things that we had -- all this data that we had to generate on our patients goes nowhere. It's reported to no one. It's like the government guy from the agriculture administration who goes out and buys the milk, the federal milk purchase, and then pumps it into the ditch, and the farmer is sitting there with a check watching all of these girls' work right down the ditch. That is exactly -- not exaggerating -- what happened. We literally did not report one stitch of it. Doctors know it, and they are like, you want me to go back, call the person, bring them back into my exam room so that I can get the correct designation of race and ethnicity -- there are 13 choices at that the Census Bureau used -- so that I can successfully get paid for my cardiology visit. They don't like that. Sorry, I'm channeling the doctor.

So the goal is to go after that cash. And we think it will hit both needs. If we can go -- we've got everybody on one instance of one application, so we see every stroke of work they do, every mouseclick of every worker in the practice, and we know that a lot of those tasks, with a little bit of artificial intelligence and a little bit of reengineering, we could -- we know for sure what they're going to do with it and we can do it for them and pull that out of their inbox, leaving more time to do things that actually we don't know because there's medicine involved.

You get -- you go through an annual exam, as a woman, you get a Pap test. The Pap test either comes back normal or abnormal. If it comes back abnormal, you have to remember there's a 32% error rate. So the first thing they do is say to the women, why don't you come back and get a retest? If that happens, the woman gets the retest. If it's abnormal again, they say, okay, now we're going to go and do a colposcopy and try to find exactly what lesion might be growing, and then maybe cut it out or maybe not depending on what we find. You don't go to medical school. That's already known. That's not science or -- that's science, not art. But we put those abnormal results in their inboxes just like any other electronic medical record, and they say, okay, I better get them back in. So, that's an example.

And there are -- we've now studied, during 2016 we did a lot of work -- about 50% of the tasks that we -- we do a lot of tasks for clients. We check the eligibility of the patients. We submit the claims. We do the appeals. We post the payments. We reconcile the cash. We send out all the prescriptions, blood tests, referrals, and orders. We do the authorizations and certifications. We match the results. We read all of the faxes that come in. We do a lot that, as a cloud-based service, is a huge competitive advantage to software companies who give you a fax server to go set up yourself to read your own faxes. But we don't yet get into that inbox. We think we can eliminate 50% of the tasks with no changes in our current artificial intelligence levels. We can do 50% of the tasks today if we crank out the execution on plans that we've got. We think that probably, by 2017, we will be more than halfway through that. And that puts us in a position to guarantee the doctors who buy in the medical group segment 20% more cash savings than they pay us for sure. And we expect that to be one of the reasons why we can keep selling through this low phase that is going to cause the regular software companies to stop. So, we expect to have that guarantee in-market in --

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Karl Stubelis, athenahealth, Inc. - SVP, CFO [7]

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Early second quarter.

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Jonathan Bush, athenahealth, Inc. - Chairman, CEO, President [8]

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-- early second quarter, within a month. And our testing of it suggests that we are going to go get not a way higher close rate than we've ever seen but the close rates that we are used to seeing in the past eight years.

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Nick Jansen, Raymond James & Associates, Inc. - Analyst [9]

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And maybe talk a little bit about some of the emerging services that you guys are working on. Inpatient has been probably a success that no one expected, at least from -- most people said, no, you can't do it and you guys have done it, 100 hospitals signed in less than the year, year and a half?

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Jonathan Bush, athenahealth, Inc. - Chairman, CEO, President [10]

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Well, it's two years.

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Nick Jansen, Raymond James & Associates, Inc. - Analyst [11]

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Two years. But in the sense of what are probably some of the larger EMR players, decades to get 100 customers. So what's the selling strategy? Why is it working and -- ?

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Jonathan Bush, athenahealth, Inc. - Chairman, CEO, President [12]

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First of all, I do believe it's one of those things. Everyone is looking at athena this way and that way, going I don't know, maybe there's a reason the stock went down they're like. But this Internet thing is going to be big. I swear it's not my idea. And we are the only cloud -- it's cheating, right? We have a connection with, out of 196,000 electronic data interchange connections with laboratories, pharmacies, insurance companies, school boards that pay their own claims from the 1970s, we've got this map of connections. You add a new doctor, a new hospital, we don't have to add anything; we don't have to set any of that stuff up. There's a huge arbitrage. They are treating the same patients they were already treating with doctors in the community, so we can reuse, because we have the rights to the data in a way that the software company doesn't, we already have their eligibility, the amount that their deductible that is utilized, whether they are allowed to get this kind of visit without an authorization. We already have that in our rules engine. So the putt is very short. It's adding the modality for a nurse to do it at the bedside, and adding drug matching before administration. These are pieces of work that are -- they take a lot of work, and we want to do it as a network service. We don't want to build features that the customer can customize on their own. So their initial thing is going to be resistant because there are people in there saying, well, I know how to set this up and you're taking away my job. And we are saying, yes, we are, we actually expect you to be fired and I'm sorry, but that's our value prop. That slows us down. But as we get momentum with it, it's just a very strong thing.

The other thing to remember is we serve very small hospitals now, so these are 50-bed hospitals. Now, there are 1,640, but who's counting, of these hospitals. There's another about 1,000 up to 200 beds. So without running into New York Presbyterian or Stanford, we've got hundreds and hundreds and hundreds of millions of dollars of addressable market. And then, over the years, our agile team can build more and more and more strong, product-centric, network-centric offerings that bigger systems will want, not just because the functionality will be there, but because the patients will be there.

What we want -- remember, in the beginning in the interim, my thought is that this healthcare Internet is going to be most useful as a place to get and access patients. When we started athena, the third year, the first year we failed, we started as a women's health clinic company. Birth centers was our idea. I was married to a midwife. So of course, I said, oh, we will build a midwife empire for you, dear. And she's like that's not what I had in mind. The midwife, she left me. But when we pivoted to trying to be kind of more of a fundamental cloud -- be an ingredient to midwife and other provider companies, which we have successfully done. We had a retreat in Rhode Island in May and we said that's all one group (inaudible) said you guys, when we get to be on the cover of the Wall Street Journal, and it's good, what does it say about us? What have we become that makes it -- in other words, when we buy a Super Bowl ad, and we don't immediately have our stock shorted, we are being so stupid as to be one of those companies that has a Super Bowl ad, what is it? The Super Bowl ad is the idea of the working mom and the dad takes the baby because it's modern, as she goes on doing business meetings, and in the middle of her lunch meeting, she keels over and the ambulance comes. And they notice on her phone the athena lead, and the paramedic says wait, wait, wait, she's on athenaNet before they put atropine in her. They said, oh no, she's diabetic, she's epileptic, she's not having a heart attack. This is a seizure, hold on a minute, and she recovers because they were able to find her chart from everybody. And that was sort of a cool pipedream idea. It involved us having a consumer-facing thing. And while we are definitely not there, we did notice that, last year, 12% of the United States ambulatory medicine was on our network and 22% of the time, it was the same patient showing up at a different customer. So, we actually start to have that, the potential for network effect. That becomes much more important than the features and functions like why did you go to rob the bank? Because that's where the money was. Why did you go to athenaNet? Because that's where the patients are. That's our ultimate aspiration. That's when we know we've become a platform and not a really cool cloud-based provider of services.

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Nick Jansen, Raymond James & Associates, Inc. - Analyst [13]

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As you talk about moving upstream, you have a partnership with the University of Toledo. We haven't heard much about that (multiple speakers)

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Jonathan Bush, athenahealth, Inc. - Chairman, CEO, President [14]

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We have room for four partnerships of 250-bed hospitals, where we are going to toy with taking our 100-bed offering and seeing if we can make it work. What will break at 250-bed? What reports are not there to be run whereas, in a small hospital, you can look through a dashboard. You literally in one page see all of the patients that are in the hospital in one screen on athenaNet. In a 250-bed hospital, you can't do that. You need different kinds of reporting and enterprise functionality.

So, the guys at Toledo have agreed to be our first. We are in negotiation with a second and we are in the sort of the pitch mode with two more we are quite sure we will be able to sell for, and certainly try to get Toledo out this year because the other one is a lot soon after, but with the learnings from Toledo, so that, by the end of next year, we will be in a position to decide maybe we move those 250-bed regional hospitals from alpha to beta and start to selectively take on some of those. Those are much bigger deals. The 50-bed hospital deals are less than $1 million each deal. They're group practice segment type deals. The 250s are more like $8 million (multiple speakers)

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Karl Stubelis, athenahealth, Inc. - SVP, CFO [15]

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This is just repeating history, right? This is, as you talked about, you started as a birthing center about 20 years ago. You started with the small, less complicated things. And four years ago, you started to enter into the enterprise segment in ambulatory, and no one said athena could do it and, four years later, it's 50% of my sales. So we've had tremendous success in actually understanding the least complicated, going with these development partners and going upscale. So, that's why it's really a signing for the future here. We started with 50 beds and we've seen how it's really responding. We are building things.

We are smarter than we were before. We are taking the learnings from the past and actually cross-selling. We are single-instance, multitenant. We are taking these rules and we are porting them over on the same code base into the inpatient space. So I look for this development cycle to be a lot shorter than the -- no offense -- than the 20 years it took to get the ambulatory (multiple speakers) is. But that's why I think the future is so bright for us in this inpatient space. I'm not even talking about the pop health side.

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Nick Jansen, Raymond James & Associates, Inc. - Analyst [16]

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And speaking of pop health, I think investors have kind of grown tired of hearing about pop health relative to the amount of buzz versus dollars. So, walk us through what you guys are doing different and why? 2017 is supposed to be a great year for you guys (multiple speakers)

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Jonathan Bush, athenahealth, Inc. - Chairman, CEO, President [17]

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This is probably bad news then for you, but one of the things I look at at the beginning of every year is the INS conference. We call it the boat show. So, it's great booths. They'll show you a new thruster on the same freaking Hinkley from 30 years ago. But our booth volume during this very sort of depressed period in the provider space was 25% higher than the previous year, which was a big surprise to me. I expected sort of a flat year. And a lot of that was population health.

So the underlying job to do with population health, population is about like dyslexia, every -- it's a word that sort of applies to everything and everyone and no one knows what it means as a result.

But the job to do that health systems are focused on are two things. One is actually much less important to them, which is they need the ability to start to product manage and guarantee their work. They need to start acting a little bit more like an insurance company, whether that's because they want to survive as an ACO, whether that's because one of the things the government -- if the new law is the new law. One of the things that was not touched is the MACRA program which, basically is driving Medicare payments to the toilet relative to inflation for doctors to chase them off of Medicare and onto either Medicare Advantage or these facacta ACOs that came out of the Obamacare program. If that's going to happen, you need to know how to run one. You need to actually know which doctors are utilizing in a way that will ruin your budget. You need to know how to find the patients that are dropping out of care and then are hitting emergency room. They call that gaps in care or utilization management.

Population health is fundamentally -- the first and least important job is to develop that competency. It's the same thing an insurance company used to do before insurance companies were just dinosaurs lying there trying to write -- we'll talk about that later -- but basically an emerging network management capability. That's the first.

The second thing and probably more important is hospitals are trying to figure out ways to build vertical monopoly power and to drive volume to their otherwise totally commoditized diagnostics. So, hospitals make all their money on labs, certain specialty pharmas, and imaging. They make 80%, 90% margins on a mammogram, which is a use of a machine that is available to anyone. The fully loaded cost of a mammogram might be $100, and they can charge $1,000 for this mammogram. They want doctors to use their $1,000 mammogram, not the $300 mammogram that's in the mobile imaging center on Route 9 kind of out in the burbs.

So the first thing they do is try to buy doctors. The first thing they did way back in the W administration is they got a law which said it's not a kickback for me to put a doctor on my electronic medical records, which, at the time and still today, was a closed system that didn't connect to the Internet and really only allowed you to order things from my hospital. And none of the doctors bought it, even for free they wouldn't buy it, and that was the great line, "Sometimes free is not cheap enough for doctors", because the systems were incredibly lame and cumbersome and the doctor just would be seeing so many fewer patients, it wouldn't be worth it.

Then Obama comes along with the High tech Act to Force them onto the medical records. Now they are back at the altar with the hospital, and they say basically I can't see my patients, so you're going to need to buy my practice. And we went, during that administration, the day the High Tech Act passed, 22% of the doctors worked for a hospital, now somewhere north of 50%. The waves hit the top of the beach and they are starting to have their first divorces and pull back. So the hospitals did not get to the full vertical monopoly that they wanted. They need that physician loyalty.

So the second wave, having tried to buy them and gotten progress, they did by a lot, the next wave is to say, okay, you don't have to buy me. You can join this thing called a clinically integrated network which allows me to give you my prices. It allows me to basically include you as part of a collective bargaining pact with me. Now, the technical -- the theoretical good intention reason for that is because we are going to manage patients in an at-risk network. But on the fee-for-service side, we're also allowed to go and just jack up our rates. So now the doctors said, what do I have to do. I don't want to switch to your EMR. We say, oh, no, no, no, all you have to do is be on our population health platform, you have to be on our care manager dashboard. We'll pull the data that we need out of your EMR, match it with the data from our EMR and the insurance company's paid claim. We'll show you a me-see picture of the patient. As long as you react to the gaps and the orders on that care manager dashboard, we are considered legally clinically integrated and we can set about negotiating rates together. That is the thing that's going on right now.

So, the wave of acquisition is over. The wave of sins, and I love that they call them sins because it's a little sinful to try to basically pretend to be clinically integrated so you can raise rates, that wave is nixed. We have a unique approach to that in that we are a cloud-based service. We don't say here's a tool which you could use to take your 1970s mumps code-based EMR and connect it to all of the doctors who are on similarly dysfunctional EMRs, which they can't operate -- they can't do it. They can't pull it off. Then you have to take the paid claims data from the insurance company for the portion of your payments that are risk contracts and add that in. So you have this big sort of traffic jam, sort of a Bangalore intersection of a little motorboat, little scooters, three wheelers going this way and a bus going that way. They're working it out, but it's really hard to buck. We do that for you as a service. We say you're going to get the care managed dashboard. We are going to go to your insurance companies, pull in the paid claims data. We are going to go to your hospital system, pull in the ADC data. We're going to do all that work to get the feeds. Then we are also going to analyze the feed for you. We're going to identify the patients with gaps in care for you, and we are going to reach out to them for you and get patients.

The third and strategic intent of this program is to get patients to feel like they are engaged with one network versus another. Hey, Betty, it's your heart. I'm considering breaking up with you. You used to take me for walks, you used to go for annual wellness visits and now you don't even pay attention to me. If you click here, I'll give you the same appointment time as you had two years ago when you actually went to your doctor's appointment. That's the kind of email and text that athena is testing on behalf of these clinically integrated networks to trick Betty, to goad Betty, to tease Betty, to beg Betty to get back engaged in care. And the theory is that Betty, at a minimum, is going to come in and we're going to get an office visit out of it. At a maximum, Betty is going to stop showing up in the emergency room every time she eats cake. And so that's the grand design of the clinically integrated network.

Our selfish intention on this is twofold. The first selfish intention of clinic -- is that there are a lot of hospitals out there that are too big for our hospital system and that are choking on an enormous capital expenditure that they just convinced their Boards of Directors to go and authorize. Literally Epic systems can be as much as $[1] billion partners, and our partners' healthcare, which is sort of a (inaudible) monopoly in our markets, $1.7 billion on a piece of enterprise software. I mean --

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Karl Stubelis, athenahealth, Inc. - SVP, CFO [18]

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They just built a five-storey building.

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Jonathan Bush, athenahealth, Inc. - Chairman, CEO, President [19]

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There is a five-storey building exclusively for the people whose job it is, the elephant handlers that will shovel up after a feed to this Epic system that will lumber through the streets. It's weird because you have like Uber and Epic, and they are in the same city at the same time. It's the strangest -- just weird. Those guys cannot go back to their board and say oops, sorry, I can't get the $1.7 billion back, but some cost logic, blah, blah, blah. This allows those customers that are already pregnant with these systems to at least begin to connect to the cloud. They take a first step to future proof themselves, to get some alternatives. Providence health, for example, is on Epic. There own 13 copies of Epic that don't talk to each other as they grew through M&A, and they are not designed the same way, so they can't even merge them. So we can be the connective tissue between them all and they can start reporting and doing their patient marketing, their centralized population health management through athena, get a little bit of technical progress without having to go and say, yes, we're going to throw out billions of dollars for the system. That gives us a chance to begin having relationships with customers who would otherwise be out of market.

The second benefit to us is that these guys can't get the independent practices in the community that didn't sell out to join with them because they don't want to be on Epic. They don't want to be hospital employees. They are doctors. We all know these kind of doctors and they represent a lot of doctors. There's a growing new generation that's happy to because there is a single workplace now, worklife balance. I deliver babies on Wednesdays and then I do claim group on Thursdays. But by and large, the independent practices that remain are not that type. We need to get to them.

When we sell a population health deal, is we who get to go and set up that practice on the care manager dashboard, which happens to look identical to athenaClinicals. So now I say hey, I'm already here, I'm already here. Do you want me to flip on ESPN the Ocho or whatever the upsell is? It's an easier, very easy upsell for us when we've already been in a practice, gotten to know the people, and set them up at a service that the hospital is paying for, so then cross-sell them onto medical records service, which looks identical, and the billing service, which just saves them -- it's just a cash flow. It doesn't change their workflow.

So those are the two things that we are -- and we really need a few of those sins to go with us so that we can get the meetings with the community practices out of it. We need a (spoken in French). We need an excuse to go meet with these practices that think that, because High Tech is over and all EMRs are the same, they don't want to meet with anybody right now.

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Nick Jansen, Raymond James & Associates, Inc. - Analyst [20]

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Great. Time is up. We'll finish this conversation downstairs at the breakout. Thanks guys.