I had heard that Judith Faulkner, the billionaire founder of Epic Systems whose U.S. share of the EHR market is near unrivaled, was milling around by herself at the inaugural ViVE conference that kicked off Sunday in Miami. I was to interview the CEO of the No.2 EHR vendor in the U.S. — David Feinberg of Cerner — onstage as part of the event on Monday and figured that perhaps Faulker would like to be have her say as well. I reached out to an Epic spokeswoman.
And so on Tuesday, March 8, which also happened to be International Women’s Day, I had the opportunity — for the first time — to hear directly from one of healthcare’s most prominent woman leaders in the media lounge of ViVE.
Faulkner is like no other top CEO I have interviewed. Most of them are surrounded by a retinue of one or more corporate communications professionals. Even lower-rung leaders from Amazon and elsewhere try to be painstakingly on message often seeking the blessing of their media relations expert before they answer a question. Faulkner came alone. It helps that Epic is not a public company so her comments will not move the market one way or another, but striking nonetheless. When at the end of the interview I asked why she was alone and not with PR folks, she theatrically looked right and left to emphasize the point, smiled and retorted, “Why not?”
As a woman, but more as a journalist, I admired her chops. But throughout the conversation, it was abjectly clear that she brooked no criticism of Epic. She believes she is building the world’s best EHR and guards Epic as fiercely as a mother would her child. Therefore, she cannot admit that the EHR she developed in Wisconsin has flaws in any shape or form. Whether that is a strength or weakness, is for you to decide. What follows is an edited version of our conversation based on the topics we discussed.
Interoperability
MedCity News: I guess the main criticism of Epic and EHRs in general is that it is a closed system. The specific criticism of Epic is that it is not particularly interoperable, and that is sort of the path that we are on right now. So do you agree with the criticism and what do you want to do about it?
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
Faulkner: My husband’s a pediatrician. I came home one day to find him very upset. He had a child that had certain problems … and was OK as long as she got the care. But she had gone to another city with her parents and got sick. They took her to the emergency room and she died. And he said over and over again if she just had her records, she would have lived.
And so I went to HIMSS and said, “When are they going to have standardization, so we can interoperate?” and HIMSS said, “Don’t hold your breath.”
I came back to Epic and I said we will not be able to interoperate but we are smart folks because we can standardize across our customers and maybe the government would follow. So we wrote Care Everywhere. This was 2004-2005 somewhere in there.
Took us about two years to write it and then nobody would use it.
They said that it was too dangerous. So finally we got some people to use it and they started talking about it and then it went like wildfire. The CEO who came to talk to our user’s group meeting said the only reason he decided to use it was because his CIO came up to him, handed some papers and said, “We need this piece of software,” so he signed it. And the said if he knew what he was signing, he never would have signed it. It took us a couple of years for people to start using it.
So they exchanged data, they talked about it, they said it was great. We went to every single customer (Faulkner pounds the table three times) and we made every single customer take it. We retrofitted it to old versions so that there was nobody in the whole U.S. who didn’t have it.
Now we have helped the government with the standards. Their standards pretty much followed the line of what we did.
MedCity News: But it’s a closed system right? I think the point that they are trying to make in the healthcare system right now is that it’s not just a matter of Epic systems talking to one another. You need to have other entities talk to Epic.
Sure. 50% of our exchanges nowadays are with non-Epic and there’s lots of other entities we go back and forth with. We do 9 million exchanges of patient records everyday. Nobody comes close to that, If you look at Cerner, be very careful — they advertise documents not patients. So you need to know how many patients does that stand for, not how many documents. We are doing more than anyone else.
The conversation then veers to other topics covered below, when Faulkner brings it back to interoperability.
Faulkner: I was talking to a customer and he said, “My Epic sites can communicate with any Epic sites in the world. And my Cerner site cannot communicate with the Cerner site across the street.” And we said, “Well then, how can we communicate with it if they can’t communicate with it?” Then we said to our staff, “Stop using that as an excuse. We have to figure out a way to communicate with them even if others can’t.” [pounds table lightly]
So we created something called Share Everywhere [holds up her phone and opens her MyChart medical record].
Share Everywhere – anywhere in the world you go that has internet, you can exchange your record and send data back. So when I heard that others couldn’t do it themselves, I didn’t want us to keep saying therefore, we can’t. And so with Share Everywhere, you can give the clinician at Eiffel Tower who doesn’t have anything except that computer — doesn’t have Epic, doesn’t have Cerner , doesn’t have Allscripts, doesn’t have anything — you can give him a code and the information will go back and forth.
So we are now interoperable with the world.
But my bigger point is — we invented interoperability and we got it out to everyone. Somehow there is this [perception that] “we don’t interoperate.”
And indeed that sentiment is definitely prevalent. I heard something at Vive from a healthcare executive that I have heard before, “Every instance of Epic is just that.” I repeated that to Faulkner who said she didn’t know what that meant. I said I took it to mean that there was no guarantee that a clinic installed with Epic can talk to another clinic also installed with Epic, across town. “That’s incorrect,” Faulkner shot back.
So I decided to find someone else at ViVE who would be able to share their experience with EHRs and interoperability. This senior executive, who has used both Epic and Cerner’s EHR systems, did not want to be publicly identified. In the comments, the executive countered Faulkner’s claim that Epic’s EHR is interoperable with Cerner’s system.
That’s just not true. These systems were not designed as platforms that easily connect with others whether that is another EHR or new features that startups would have to access. As much as we have had some level of transformation in tools to support providers and patients, we are not in a place of true interoperability.
Hospitals have to invest in expensive middleware, the same middleware you would need to connect to startups efficiently to get EHRs to talk to one another. Or you have to invest in large IT departments that create highly customized integration solutions that need a huge amount of maintenance.
Yes, they can eventually talk to one another but you need to invest in significant resources to get to that place and it’s no walk in the park.
Artificial Intelligence
MedCity News: Let’s talk about AI. I think there have been some missteps at Epic with AI as it relates to sepsis prediction. So I think there are people out there that want you to describe how you are coming up with these algorithms because the power of AI is awesome both for its potential for good and harm. So what are the some of the lessons learned for you?
Faulkner: Let me back up a bit. AI has been around forever. AI started in the very beginning when software started. When I stand by the elevators I think, there’s AI in the elevators to figure out which one should come to you. So AI is ubiquitous. There’s two kinds of AI. One is the kind that looks at something and alerts you so, you the doctor are going to order medicine for somebody who is allergic to that and the AI says no, don’t do it. We have tons of alerts like that going out all the time. The other kind of AI is one that delves into all the information and tries to figure out what conclusions can I draw from the information so that I can help people paint a picture. On the sepsis, what do you mean by missteps?
MedCity: Here’s what I found online. Called Epic Sepsis Model, the tool is included as part of Epic’s EHR and The University of Michigan Medical School in Ann Arbor found its output to be “substantially worse” than what was reported by the vendor when applied to a large retrospective sample of 27,000 adult Michigan patients.
Faulkner: I don’t think it was actually applied. It was theoretically applied. Big difference.
A very capable spokesperson provided more detail about the Epic Sepsis Model via email following the interview.
- The full model, mathematic formula, and accuracy measurements are available to every customer.
- The authors used a hypothetical approach. They did not take into account the analysis and required tuning that needs to occur prior to real world deployment to get optimal results.
- In order to predict who might become septic, the model is trained on past patients who had a clinical diagnosis of sepsis.
- The University of Michigan still uses Epic’s sepsis model in their hospitals as part of nurse screenings.
MedCity News: What are you excited about in healthcare?
Faulkner: So we are doing a lot of stuff that’s very very cool. We’re linking payers and providers together and that is helping speed up pre-auths and it is reducing gaps. I think that is wonderful.
We are creating Cosmos. Do you know what that is?
MedCity News: No
Faulkner: Go to epicresearch.org. It has 2.2 billion provider visits. That’s huge. About 140 million patients. What we are doing is that many of our customers are sharing data with us, de-identified, and using it for studies. The studies are being picked up all over the country by hundreds of journals. The study that you probably saw on reduction of cancer screenings — that came from us. That’s one exciting thing.
I think this one is reaaally exciting. What we’re doing — and we’re writing it now — called Best Care for my Patient. This is not the final name.
You are the clinician. You are taking care of me — maybe I have hypertension and diabetes. Cosmos goes and looks across those hundreds of millions of pieces of information and finds everybody who has these conditions and then compares the outcome from what the drug treatment was given and presents that to the clinician and so the clinician no longer has to use anecdotal data. We are pulling the evidence from that huge bank of data right in front of the clinician so that clinician can make a very educated decision.
MedCity News: So Cosmos is the engine that supports this evidence.
Faulkner: No, Cosmos is the database that keeps the data. Epicresearch.org is open to anybody.
MedCity News: You have been leading Epic for a long time. What are your goals for the company?
To have the best EHR in the world. I want “Best Care for my Patient” to get out – that’s one my main goals. Ease of use for the doctors is critical. I wrote the original code … and so we started as a clinical information system. So what I really want is for all the work we’ve done to make the system easier and easier to use, how do we get our customers to take it? Maybe they’ve had the software for 12 years. They need the software we have now to make it easy and replace their old stuff with the new stuff and the old workflows with the new workflows, and that’s a hard job.
It’s great to hear Faulkner mention how she is focused on making the EHR easier for doctors to use. That will indeed be meaningful. So, I sincerely hope Epic executives are discussing burnout because that’s a term that was conspicuous by its absence in our one-on-one interview.
Photo: Steven Ferdman Getty Images
Editor’s Note: An earlier version of the story didn’t note that MedCity News is a partner of HLTH, the organizer of ViVE.
