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Four points about the strategic significance of Epic in healthcare

Writer's picture: Amanda BerraAmanda Berra

An excerpt from our Strategy Bootcamp for non-technologists


Epic is a major force in today's healthcare industry, creating opportunities, threats, constraints, and other strategic conditions for a wide variety of healthcare players. At this point, all healthcare executives need to be conversant about Epic and related EHR market dynamics—including the non-technologists among us whose bailiwick this typically isn’t. Thus we recently created and released to Union members a Strategy Bootcamp module on Epic and the EHR landscape. The Strategy Bootcamp series is our "102" for executives who know a lot about healthcare, but not some particular topic within it. Each bootcamp overviews key concepts, trends, controversies, and more.

I'm on a lifelong quest to keep from cramming too much content into every single deliverable I create, so in this post, I'm going to hit just four basic points about Epic in healthcare:

  1. Epic is the player everyone has to be cognizant of, which is not always easy to do because it's an 'off the record only' topic for many insiders

  2. Epic is coming to dominate the market for more than one reason

  3. Integration with Epic is a must-have capability for third-party tech/service vendors—but 'integration' can mean many different things

  4. There are multiple controversies simmering about Epic's role in healthcare, especially the fact that it has become a de facto gate for any player looking to participate in healthcare delivery

Union members, you can access a recording of the full webinar or the deck for information beyond what I'm covering today.

A summary of what factors make EHR, and Epic, both important and tricky topics in healthcare.

Point 1: Epic is the player to be aware of in the EHR space today—even though, or maybe especially because, it's an off-the-record topic for many

Let's start with the timeline

Since 1979, Epic has gradually grown from a data analysis, and then scheduling and billing software company, to today’s massive, and determinedly privately held, EHR player. It now handles over 325 million patient records and $5 billion in revenue per year. Key milestones along the way include a move to Verona, WI; whenever you hear fellow healthcare leaders talking about “Verona” or “the folks from Verona”– this is metonymy (word of the day!) for Epic.

The 2010 passage of the HITECH act was also a massive milestone in the development of Epic, as it provided tremendous market momentum in the form of EHR uptake incentives/penalties for Epic and other “certified” EHR solutions. (“Certified” means approved by the government as having enough robust functionality, security, privacy, etc., to qualify as a tool that meets federal requirements for provider EHR use). You can count Epic's participation in that process among its many market controversies; more on that shortly.

A timeline of major milestones in the corporate history of Epic Systems

Epic’s distinctive company personality in a nutshell

Judith Faulkner, the now 81-year-old CEO, is an outsized personality known widely among healthcare executives as “Judy.” What do I mean by having an outsized personality? In addition to leading this massively successful company from its beginning to today, she is also the creative mind and driving force Epic’s strategy and culture, including the whimsical, story-themed campus. At the 2024 User Group, as part of the storybook theme, she took the stage dressed as a swan.

The company has some surprising tenets and practices as compared to its competitors – e.g., they don’t accept institutional money; they have vowed not to acquire other companies or go public; and they don’t bring in executives from the outside but instead promote from within. As an employer of healthcare technology and business talent, the company has a reputation similar to Google or Amazon, namely, it’s a terrific imprimatur and achievement to have on one’s resume, but the work is reputed to be grueling.

The fact that Epic has grown up as a single company, as opposed to adding capabilities by way of M&A, is important from a technical perspective because unlike competitors whose work has been cut out for them in knitting together disparate tech as they add companies, Epic’s tech is largely built on one historical platform.

Supporters say the fact that all functions are built onto a legacy platform makes it more cohesive. Critics say it has also put the company into major “tech debt”, potentially hindering innovation.

A summary of some of Epic's corporate quirks, including its strong-personality CEO, whimsical custom campus, and industry reputation as a tough but career-making employer.

Why Epic is an off-the-record topic for many

A few years ago, I tried using LinkedIn to start a discussion about why, every once in a while, a hospital or health system will get to the brink of bankruptcy due to an EHR implementation. Wisely, I thought, I first discussed the questions directly with some people I knew would have good perspectives on this; when I said I was going to post something about it on LinkedIn and asked if they wanted to share their thoughts there, they said yes. However, when I posted the question, most of the people I had talked to ended up not responding at all, and some of the people who did left out all the main points they had made when we talked beforehand.

What did I not fully grasp at that point? The fact that many healthcare executive types will not touch the topic of Epic, and especially not problems or issues with Epic, with a ten-foot pole. Not in public, and often not even in small-group conversations outside a trusted circle. Here's why:

  • Confidentiality. Epic is known for its extensive use of non-disclosure agreements (NDAs), which apply not only to its own employees but also to customers, potential customers, consultants, and even developers working inside Epic client organizations. Screenshots of Epic’s software are strictly prohibited, and while there is debate over whether its contracts contain explicit non-disparagement clauses, many in the industry believe they do—or at least act as if they do. Whether the restrictions are real or simply perceived, the effect is the same: an industry-wide reluctance to openly discuss anything that could be interpreted as criticism.

  • Professional incentives. Among provider IT leaders, particularly CIOs, Epic is more than just a technology vendor—it’s a professional network, a credential, and in some ways, a career safety net. For many CIOs who have led large Epic implementations, their relationship with the company is one of their most valuable professional assets. If they ever move on from their current role, their ability to land another position may depend on being viewed as a strong Epic partner. This creates a dynamic where the relationship with Epic can feel as important—if not more so—than the relationship a CIO has with their own employer.


  • Current or future partnership or cooperation imperatives. Executives at many third-party healthcare service and technology companies, and even some roles within payer or life sciences organizations perceive working constructively with Epic as essential for protecting/advancing their companies' interests. For many, the safest approach is to keep direct critiques off the record and focus instead on fostering a collaborative relationship within the parameters Epic sets.


The result is an unspoken industry norm that discussing Epic candidly is not worth the risk. The more Epic comes to dominate the market (more on this in a second), the more this is the case.

Summary of factors making Epic an off-the-record topic for many in healthcare.

Point 2: Epic is coming to dominate the EHR market for more than one reason

Epic leads the EHR market in terms of hospital share, generally pegged at about 40% overall and considerably higher among larger hospital systems. Nearly all of the “tier-one”, national-name, major systems, especially AMCs are either on Epic now, or are in the process of switching.

Two recent examples of high-profile systems switching to Epic: Intermountain and UPMC. In both cases, systems executives interviewed by journalists (remember: on the record!) named the most common reasons for a system to switch to Epic:

  • Epic’s general technical performance: Advanced features, positive clinician experience compared to other EHRs, etc.

  • The fact that within itself, Epic is highly interoperable: All the modules work well together; for a big, multi-site system, moving to such an environment is a lot less complex (in a good way), more streamlined, more coordinated than what was often previously the case, which was having multiple kinds of EHR within the walls of the system.

Overview of statistics and cases relating to Epic's dominant role in healthcare - market share and major systems switching to its platform.

Setting aside Intermountain and UPMC, and now talking generally about the shift of large health systems to Epic: There are at least two additional reasons beyond technical performance for any given system to switch to Epic. Both are commonly referenced in the industry, but don't tend to make it into a press release. These off-the-record rationales for moving to one enterprise-wide system include:

  • The “one point of accountability” benefit – most CIOs and CTOs are overwhelmed by the number of vendors they need to manage these days and it helpful to have the bulk of the EHR system flowing through ONE source. 

  • At this point, Epic is the conservative choice: Along the lines of “you will never be fired for going with the market leader”, the more major systems switch the Epic, the more board-level discussions morph from “should we consider switching to a new EHR?” to “So, why are we not switching to Epic if everyone else is?”


Point 3: For many third-party tech/service vendors, integrating with Epic is an essential—but 'integration' can mean many different things

Today's healthcare market features a huge ecosystem of technology and service companies in healthcare for which integration with Epic is an existential imperative. These players need access to EHR data and/or integration with the EHR so as to be able to play whatever role they aspire to play in clinician workflow at the point of care.

To understand why so many different kinds of companies need to be able to plug into the EHR, and Epic specifically as it becomes the dominant EHR in the market, consider the following examples:

  • There is a whole class of interoperability vendors that serve other tech/service companies in healthcare, helping others interoperate with and draw data from across different EHRs. These companies need to be able to work with all EHRs, but especially Epic because of its massive user base.

  • Clinical decision support vendors need EHR data to generate the insights that turn into guidance for clinician decisions—and, they also need to be embedded into the EHR interface in order to have their tools actually used at the point of care by clinicians.

  • Patient engagement tool vendors need EHR data in order to personalize the communications and guidance they are providing to patients–they need to know something about the patient’s situation in order to prompt them to do different things. Sometimes they also need to be able to put information back into the record for care coordination purposes.

  • Data aggregators/analytics vendors need to draw EHR data to produce insights, generate data visualizations and populate analytical tools for providers or other users. Often, they want these tools to plug into EHR for providers' easy access.

  • Revenue cycle companies want access to EHR data to support or check claims, reduce risk of denials, assess appropriateness of care and so forth.

An explanation of how different third-party tech vendors have to integrate with all EHRs and especially Epic.

'Integration’ with Epic can mean many different things

While some kind of access to data/involvement with Epic's interface is necessary for many different kinds of companies, there is not one single way to be integrated, Instead, there are a variety of ways and levels. Since most products/services merely lead with "yes we are integrated with Epic," one often needs to dig to understand what KIND of integration is happening between a third-party vendor and EHR/Epic.

Below is an illustrative graphic depicting the concept of levels of integration that a third-party vendor could have with Epic. Integration levels start at the bottom with least sophisticated, least extensively integrated, and least expensive (to the vendor) ways of interoperating. As the levels go up, so does the expense (again, to the vendor), the sophistication/seamlessness/extent of the integration, and probably the quality of output.

I want to draw everyone's attention ehre to the word "illustrative" in the graphic. It's an important caveat because Epic does not publish this information anywhere, it won't explain in any kind of detail what the integration levels are or what privileges there are for each level. This is a concept and fact base that you have to piece together by talking with people (off the record). Different people have slightly different descriptions of the names, manner of cooperation, privileges and costs of these different integration levels; plus, they all change over time.

A graphic explaining in general/illustrative terms the different levels of integration a third-party tech company can have with Epic.

Point 4: There are a range of criticisms and complaints about Epic in healthcare

It's hard to overstate how controversial Epic is among healthcare executives right now (even if many keep their criticisms off the record). There are a range of debates, some of which date back to the HITECH act.

In my view, the most important issues to track are the current ones, especially the gatekeeper problem and its related moving pieces.

  • The gatekeeper problem relates to the idea that Epic, as a platform, is picking winners and losers. Only products and solutions that are either offered as part of Epic itself (proprietary modules), or those that are chosen for higher levels of integration, are likely to be picked by health system executives looking for cohesiveness in the EHR platform. Suboptimal solutions may often be picked for that reason.

  • Closely related: the roadmap problem. Critics say that the Epic roadmap—that is, its forecast of capabilities it will develop in the near future even if they don't exist yet—is way too sprawling. Critics say that its sheer breadth is having a chilling effect on the marketplace for innovation in healthcare technology in general, because Epic can effectively freeze the market for any new/future solution while system executives (especially heavily Epic-aligned CIOs) wait to see if a given functionality will be included in Epic down the road.. Among critics, you often hear questions like “Will there be anything left?” in terms of major healthcare technology spaces that Epic does NOT dominate.

Summary of industry complaints about the role of Epic in healthcare.

It's important to remember the flip side argument: An Epic defender’s viewpoint

Among fans, you will hear the flip side argument of Epic as a platform, and even its gatekeeping ways. Fans will reject the idea that Epic is chilling healthcare technology innovation by arguing that in fact, it is bringing in innovative tools (such as AI, through partnerships with Nuance, Microsoft, and Abridge—topic for another day) in a safe and tested way into the system.

Epic defenders will also point out that, while third party vendors bring up many issues with integrating with Epic, Epic is currently meeting or exceeding all interoperability regulations and requirements. And that, in fact, Epic solutions tend to be extremely interoperable AMONG PROVIDERS,  and sites, at least in the ‘treatment’ use case for EHR data.

And lastly, re-stating the 'single point of accountability' argument from earlier in this point, remember that for many system executives. Epic's filtering, gatekeeping, or curating function is considered a feature, not a bug. We are living in a world in which many believe they simply cannot assess, keep up with, or manage the sheer number of different technology vendors that are out there. If Epic is filtering out bad actors and security risks and just streamlining things for provider executives–many view that as a distinct benefit.

Summary of defenses that supporters would make about Epic in healthcare.

Keeping an eye on the Particle Health case

For those following the ongoing debate about Epic’s influence in healthcare IT, the Particle Health v. Epic lawsuit is a case worth watching. While discussions of Epic’s dominance often center on its sheer market share, the real question from an antitrust perspective is whether its business practices cross the legal line into anti-competitive behavior under the Sherman Antitrust Act. Enter Particle Health's complaints.


Particle Health is a health data exchange company that provides an API platform designed to make it easier for organizations to access and integrate patient medical records from various health systems. It positions itself as a solution for improving interoperability, allowing clients—including some healthcare providers, digital health companies, and other third parties—to pull patient data more seamlessly., Particle Health claims that Epic unfairly restricted its access to Carequality, an interoperability framework that facilitates data exchange across different EHR systems, thus preventing it from offering data-sharing services to its clients. Particle Health further argued that Epic, in general, uses its position to suppress competition by imposing restrictive licensing agreements and high fees that make it difficult for smaller players to operate effectively.


Epic, for its part, has argued that restricting ParticleHealth access to its data was necessary to ensure compliance with HIPAA privacy rules and that some of Particle’s clients were improperly requesting patient data for non-treatment purposes. The Carequality Steering Committee investigated and found that two of Particle Health’s customers had submitted inappropriate data queries, leading to their suspension from the network. Epic has since filed a motion to dismiss the case, asserting that its actions were both legal and justified.


There are lots of interesting points to make about this lawsiot but, probably most relevant to the general conversation is how, assuming it is not successful, it points to the limits of antitrust enforcement when it comes to companies like Epic. Under U.S. antitrust law, not only are organic monopolies perfectly legal, but also exclusionary behavior is not necessarily illegal unless it harms competition itself, not just individual competitors. Again, Epic consistently points to its compliance with 21st Century Cures Act interoperability mandates and maintains that its practices prioritize patient privacy rather than blocking competition.


Summary of the Particle Health vs. Epic lawsuit - which helps explain some of the issues that some particles have with Epic and its market-dominant role in healthcare.

This, of course, is a major theme in healthcare policy today, i.e., the idea that the antitrust framework we have may not be well suited for the challenge of addressing healthcare's various market consolidation issues, especially after the fact (versus preventing new M&A).


Looking for more on this topic—and/or, more executive '102s' on other issues?

  1. Union members: Access our recorded webinar on this topic

  2. Union members: Sign up now for upcoming Strategy Bootcamps!. Across the spring we will be tackling 'how to speak' ambulatory, risk and value-based payment, and post-acute/home-based care

  3. Everyone else: Please reach out for more information, and keep an eye out for future posts about Union's Strategy Bootcamp series. Scroll to the bottom of this page to sign up for our mailing list.

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