Epic Systems Corporation (commonly known as Epic) is an American privately held healthcare software company based in Verona, Wisconsin. According to the company, hospitals that use its software held medical records of 78% of patients in the United States and over 3% of patients worldwide in 2022.[4]
History
Epic was founded in 1979 by Judith R. Faulkner[5] with a $70,000 investment[6] (equivalent to $290,000 in 2023). Originally headquartered in Madison, Wisconsin, Epic moved its headquarters to a large campus in the suburb of Verona, Wisconsin in 2005,[7] where it employs 13,000 people as of 2023.[8] The campus has themed areas/buildings, such as a castle-like structure, a shipwreck-themed building, a "Wizard Campus" that appears to be inspired by J.K. Rowling's Harry Potter, and a dining facility designed to mimic London King's Cross railway station.[9]
As of 2015, the company was in the fifth phase of campus expansion with five new buildings each planned to be around 100,000 square feet.[10] The company also has offices in Bristol, UK; 's-Hertogenbosch, Netherlands; Dubai, United Arab Emirates; Dhahran, Saudi Arabia; Helsinki, Finland; Melbourne, Australia; Singapore; Trondheim, Norway; and Søborg, Denmark.[11]
Product and market
Epic primarily develops, manufactures, licenses, supports, and sells a proprietary electronic medical record software application, known in whole as 'Epic' or as Epic EMR. The company's healthcare software is centered on its Chronicles database management system. Epic's applications support functions related to patient care, including registration and scheduling; clinical systems for doctors, nurses, emergency personnel, and other care providers; systems for lab technologists, pharmacists, and radiologists; and billing systems for insurers. MyChart is used by patients to access doctors’ records, schedule appointments, review and re-fill medications, message their care team, and for billing purposes. It is used by 150 million patients across the US.[12]
Epic also offers cloud hosting for customers that do not wish to maintain their own servers;[19] and short-term optimization and implementation consultants through their wholly-owned subsidiary Boost, Inc.[citation needed]
Epic has several data resources and analytic tools. Cogito is the analytic environment consisting of the Epic data warehouse and analytic capabilities. The different levels of the database architecture are Chronicles, Clarity and Caboodle.[21] Chronicles is Epic's real-time database; the data the user enters is immediately available in Chronicles.[22] Clarity is a relational database and Caboodle is an enterprise data warehouse platform.[23] These databases can be queried using a variety of tools within Cogito such as Reporting Workbench[24] and SlicerDicer.[25]
Criticisms and controversies
Profit maximization and provider fatigue
Robert Kuttner writes for The American Prospect that Epic's market dominance is driven by its software's ability to maximize profits for hospitals by facilitating upcoding, a form of healthcare fraud.[26] The Department of Health and Human Services found that from 2014 to 2019, the number of inpatient stays billed at the highest severity level increased almost 20%, while stays billed at lower severity levels decreased.[27]
Kuttner argues that this drive for profit maximization leads to providers spending two hours entering data for every hour they spend with patients, including significant time outside of working hours. Based on interviews with providers, much of this data is clinically irrelevant.[26] While Epic provides time-saving tools, one hospital executive argues that these are attempts to solve problems exacerbated by Epic.[26] Kuttner also reports that providers are faced with time-consuming training, alert fatigue, and mistakes stemming from copying and pasting from previous notes, ultimately leading to burnout and early retirements.[26]
David Blumenthal, the National Coordinator for Health Information Technology from 2009 to 2011, said "The customers [of EHRs] were the chief information officers and the chief executives of hospitals, not doctors. Their principal goal was to protect revenues. Systems like Epic were not designed to improve quality because there was no financial incentive to do so at the time."[26]
Data sharing and anti-competitive practices
Care Everywhere is Epic's health information exchange software, which comes with its electronic health record (EHR, or EMR) system.[28] A 2014 article in The New York Times interviews two doctors who said that their Epic systems would not allow them to share data with users of competitors' software in a way that will satisfy the Meaningful Use requirements of the HITECH Act. At first, Epic charged a fee to send data to some non-Epic systems.[29] Epic said the yearly cost for an average-sized hospital was around $5,000 a year.[28] However, after Congressional hearings, Epic and other major software vendors announced that they would suspend per-transaction sharing fees.[30] Epic customers must still pay for one-time costs of linking Epic to each individual non-Epic system with which they wish to exchange data; in contrast, Epic's competitors have formed the CommonWell Health Alliance which set a common Interoperability Software standard for electronic health records.[30] A 2014 report by the RAND Corporation noted the software was difficult and costly to use in conjunction with other billing systems.[31] The report also cited other research showing that Epic's implementation in the Kaiser Permanente system led to efficiency losses.
In September 2017, Epic announced Share Everywhere, which allows patients to authorize any provider who has internet access to view their record in Epic and to send progress notes back.[32] Share Everywhere was named Healthcare Dive's "Health IT Development of the Year" in 2017.[33]
In September 2024, Particle Health, a healthcare startup, filed suit accusing Epic of antitrust violations stemming from Epic's position in sharing health data with third parties.[34] Prior to this lawsuit, critics had questioned whether Epic operates as a monopoly.[26][35]
After 2.1 million records were transferred to Epic systems, it developed serious problems and the system became unstable.[38] Ambulances were diverted to other hospitals for five hours and hospital consultants noted issues with blood transfusion and pathology services.[39] Other problems included delays to emergency care and appointments, and problems with discharge letters, clinical letters and pathology test results.[37] Chief information officer, Afzal Chaudhry, said "well over 90% of implementation proceeded successfully".[36]
In July 2015, the BBC reported that the hospital's finances were being investigated.[40] In September 2015, both the CEO and CFO of the hospital resigned.[41] Problems with the clinical-records system, which were said to have compromised the "ability to report, highlight and take action on data" and to prescribe medication properly, were held to be contributory factors in the organization's sudden failure.[42] In February 2016, digitalhealth.net reported that Clare Marx, president of the Royal College of Surgeons of England and member of the NHS National Information Board, found that at the time of implementation, "staff, patients and management rapidly and catastrophically lost confidence in the system. That took months and a huge amount of effort to rebuild."[43]
Danish experience
In 2016, Danish health authorities spent 2.8 billion DKK on the implementation of Epic in 18 hospitals in a region with 2.8 million residents.[44][45] On May 20, Epic went live in the first hospital. Doctors and nurses reported chaos in the hospital and complained of a lack of preparation and training.[45]
Since some elements of the Epic system were not properly translated from English to Danish, physicians resorted to Google Translate. As one example, when inputting information about a patient's condition, physicians were given the option to report between the left and the "correct" leg, not the left and right legs. As of 2019, Epic had still not been fully integrated with Denmark's national medical record system. Danish anesthesiologist and computer architect Gert Galster worked to adapt the system. According to Galster, these Epic systems were designed specifically to fit the U.S. health care system, and could not be disentangled for use in Denmark.[45]
An audit of the implementation that voiced concerns was published in June 2018.[46] At the end of 2018, 62% of physicians expressed they were not satisfied with the system and 71 physicians signed a petition calling for its removal.[45][47]
Finnish experience
In 2012, the Hospital District of Helsinki and Uusimaa (HUS) decided to replace several smaller health record systems with one district-wide system created by Epic. It was called Apotti and would be used by healthcare and social services for the 2.2 million residents in the HUS area. The Apotti system was selected as the provider in 2015 and implementation started in 2018. By November 2022, the Apotti system had cost 625 million euros.[48]
After the implementation, complaints from healthcare workers, especially from doctors, started accumulating. The system was accused of being too complicated and that its convoluted UI was endangering patient safety. For example, one patient was administered the wrong chemotherapeutic drug due to an unclear selection menu in the system.[49]
In July 2022, a formal complaint demanding that the issues in the system be fixed or the system be removed entirely was sent to the Finnish health care supervising body Valvira. The complaint was signed by 619 doctors, the majority of whom were employees of the Hospital District of Helsinki and Uusimaa (HUS) and users of Apotti.[50]
Swiss experience
Luzerner Kantonsspital (today LUKS Gruppe) was the first hospital in Switzerland to introduce Epic in any German speaking country worldwide in September 2019. In March 2024 Inselspital (Insel Gruppe) in Berne followed. Using the full potential of the Epic software including AI applications is challenging for both groups.
Norwegian experience
Central Norway started introducing Epic (branded “Helseplattformen”) in November 2022. After approximately two months, the public broadcaster NRK reported that around 25% of the doctors at the region's main hospital considered quitting their job, and that 40% were experiencing stress related health issues due to the new IT system.[51] Previously, health personnel actively demonstrated against the software by marching through the city of Trondheim.[52] Due to the chaos ensuing the introduction, including 16.000 letters not being sent to patients, the Norwegian CEO of the Helseplattformen IT project, Torbjørg Vanvik, had her employment ended by the board.[53] Unexpected cost increases forced the authorities to decrease efforts in other areas, such as a planned initiative on mental health.[54] Employee representatives state that the public will receive ”significantly worse services“.[55] A year after implementation over 90% of doctors in the affected hospitals considered the Epic system a threat to patient health,[56] and hospital staff organised large protests at seven hospitals that had or were planning on implementing Epic systems.[57]
COVID-19 response
In 2020, the novel coronavirus pandemic spread in the United States. Epic Systems faced considerable criticism for their initial plan to have their 10,000 employees return to work on-campus.[58] Employees expressed concern about returning to the office, with the first group being required to return as early as August 10 while the pandemic continued to spread.[59] This plan was abandoned temporarily, and as of December 2020, employees were still able to work from home.[60] The plan had come about despite a Dane County public health order requiring remote work "to the greatest extent possible."[61] Criticism revolved in particular around the fact that employees were being ordered back to preserve the company "culture," despite CEO Judy Faulkner's admission that work was getting done remotely.[62] According to The Capital Times, who interviewed 26 Epic employees about the plan, "13 [employees] said they have knowledge of managers being demoted for expressing concern about the company’s plans to bring its nearly 10,000 workers back" to on-campus work, and all requested anonymity for fear of employer retribution.[63]
In a survey of over 400 Epic employees in 2020, 89% of respondents expressed dissatisfaction with how Epic was handling the pandemic.[64]
As of January 2022, Epic employees were required to work in the office almost daily and are given 10 half-days for remote work annually.[65]
