How Epic won over academic medical centers

With New Hyde Park, N.Y.-based Northwell Health switching to Epic, the EHR vendor now has a unique distinction: It will be used by every health system on U.S. News & World Report's best hospitals list.

In fact, with 231 teaching hospitals under its belt, Epic controlled nearly 60% of the academic medical center market in 2022, KLAS Research reported. Epic was the only EHR vendor to pick up any academic hospitals in 2022, with four (Oracle Cerner, Meditech and Altera Digital Health each lost one). More than 90% of medical students and residents now train on Epic.

"I would expect more academic medical centers to move to Epic," said Kristin Myers, executive vice president and chief digital and information officer of New York City-based Mount Sinai Health System, which launched Epic in 2006. "The ability to exchange clinical information between organizations, the amount of clinical teams that have used Epic at other institutions, and the sophistication of the product will lead to other transitions."

While Epic is "not cheap," its successful track record of implementations means "you get what you pay for 100% of the time," said Jeff Gautney, senior vice president and CIO of Chicago-based Rush University System for Health, which switched to the EHR systemwide in 2007.

"I think the battle is over, particularly with the acquisition of Cerner by Oracle," Mr. Gautney told Becker's. "While there will be choices at the lower end of the market, the failure of Cerner to ever deliver an effective and integrated revenue cycle solution has doomed it and ceded the high ground to Epic. The next battlefield is not in the U.S. market but overseas, where Cerner has a stronger foothold but Epic is quickly overtaking them. I cannot imagine a U.S.-based academic health center selecting any solution other than Epic at this point."

Cerner maintains 2nd place

Oracle Cerner, solidly in second place, was used by 131 teaching hospitals in 2022, accounting for 34% of the market, KLAS reported. Altera Digital Health (formerly part of Allscripts) had 16, while Meditech had eight.

"One of the best things about Cerner is the ability to configure to meet the organizational needs," said Gerald Kelly, DO, CIO of Stony Brook (N.Y.) Medicine, a Cerner client. "As an academic health center, we have been able to leverage their population health platform extensively for data analytics, quality initiatives, research needs and data collection."

Dr. Kelly said he is looking forward to advancements in the EHR from its new parent company. "The Oracle vision is that all Oracle Cerner systems will move into the Oracle Cloud Infrastructure and apply cutting-edge artificial intelligence tools throughout the platform," he said.

Cletis Earle, senior vice president and CIO of Hershey, Pa.-based Penn State Health, said the ability to customize Cerner was initially an advantage for his health system but has since turned into a liability.

"We realized it was very hard to remain standard, particularly from iteration after iteration, upgrade after upgrade," he said. "When you customize something to such an extent, it's very difficult to maintain." Epic, he noted, went from a configurable to a standardized approach.

But he said he's "optimistic" after attending the recent Oracle Health Conference, at which Oracle co-founder Larry Ellison detailed how the EHR would be hosted in Oracle's cloud, though Mr. Earle said he would have liked to learn more about Cerner's plans for its entire application portfolio and the development timeline.

He said Mr. Ellison's plan to connect all the major cloud providers and create a unified health record would be a "nirvana state" for healthcare and interoperability — "if he's able to pull it off." Mr. Earle also attended a private preview of Oracle Cerner's generative AI solution but said: "I don't think the technology is ready."

Mr. Earle said he expects Cerner to be in a much better position two to three years from now but that it will continue to lose academic medical center clients in the meantime. But the company's market focus could shift — it does quite well with small hospitals, he noted. In 2022, it picked up 11 standalone hospitals with one to 25 beds and 21 hospitals with 26 to 200 beds, the most of any EHR vendor in both categories, per KLAS.

While Penn State Health is sticking with Cerner for now, Mr. Earle said "it's our fiduciary responsibility to look at all options that are out there."

Other health systems with academic hospitals on Cerner include IU Health (Indianapolis), MedStar Health (Columbia, Md.), UAB Medicine (Birmingham, Ala.), University of Missouri Health Care (Columbia), and Baystate Health (Springfield, Mass.), according to Definitive Healthcare.

UPMC (Pittsburgh), Boston Children's Hospital, Memorial Hermann Health System (Houston), and Methodist Le Bonheur Healthcare (Memphis, Tenn.) are among the systems with academic medical centers switching from Cerner to Epic. Oracle Cerner did not respond to requests for comment for this story.

New York City-based NYU Langone Health went to Epic across the organization in 2009 as part of its "one patient, one chart" philosophy, said Nader Mherabi, its executive vice president and chief digital and information officer. The health system has since brought three hospitals under its umbrella, quickly integrating them into Epic. Mr. Mherabi said the EHR helped make the acquisitions more "seamless" overall.

"It has provided us with a single source of clinical data across our inpatient and outpatient locations that we now use to track trends and metrics across a suite of dashboards to drive organizational excellence," he said. "This has led to data transparency that lets us benchmark performance and create positive change, facilitating our efforts to advance productivity, quality and safety metrics."

'You're in or you're out'

Epic got in the door with academic medical centers because of its integrated platform across ambulatory and inpatient care, said Christopher Sharp, MD, chief medical information officer of Palo Alto, Calif.-based Stanford Health Care. For instance, Stanford's children's hospital switched from Cerner to Epic because of its more robust ambulatory offering.

He said the vendor also provided a strong community EHR, a core functionality that can support complex healthcare environments, and an interoperable record exchange with Care Everywhere, which is critical because academic medical centers rely on specialty referrals.

Epic kept academic health systems' business by continually developing integrated solutions, staying engaged with clients, and cleverly writing contracts to incentivize upgrades and adding features, Dr. Sharp said.

Epic's reign, however, raises the "existential question" of whether it's good for EHR competition or healthcare in general, he said. "My colleague said, 'Look, you used to be worried about Skynet, but they're not so dominant," Dr. Sharp said with a laugh, referring to the fictional AI network that threatened humanity in The Terminator.

He also pointed to Epic's Cosmos informatics platform, which aggregates data from 217 million patient records for researchers to draw clinical insights from. "That's of great value to an academic organization. Where else can you get on a platform that has 210 million lives of data? This is kind of extraordinary," he said. "The bad news is that it's going to be Epic-centric. And just like the other things that have fueled Epic's dominance, part of it is the walled garden of being an Epic client."

Dr. Sharp compared the EHR vendor to Apple, which similarly has an "amazing" suite of products. "But not every patient uses an Apple phone. So what do we do?" he said. "Not every academic or not every community health system will use Epic. So how will we maintain a dataset that is representative of the population? What will happen when some people are in and some people are out of that data exchange framework or data aggregation framework?"

"This is the yin and yang of Epic being a dominant player," he added. "You're in or you're out."

Interoperability vs. integration

Epic's dominance among academic medical centers shows that "integration" has beaten "interoperability" as the best EHR approach, said Michael Restuccia, senior vice president and CIO of Philadelphia-based Penn Medicine.

He defined interoperability as "we'll take the best little niche systems and somehow or another, we'll tie them together and it'll be glorious."

"Within ambulatory, if you remember back, every specialty had their own EMR," he said. "We have 30-plus specialties. So we had at least 30-plus niche EMRs supporting them, because sometimes we had multiple EMRs for the same specialty. Just think through this: That's 30-plus contracts, 30-plus maintenance agreements, 30-plus vendor representatives that you have to keep track of, 30-plus interfaces."

Now Penn Medicine has one: Epic.

"When you're trying to run a complex health system, integration trumps interoperability every day," Mr. Restuccia said.

He said he's not a "groupie" or "cheerleader" for Epic, by any means. "We hold them accountable. And we hold all of our vendors accountable," he said. "But Epic seems to hold its people accountable to a higher level, and that's one of the things that's helped make us successful. And I've shared with Judy Faulkner and others that every day they make folks like me look good.

"For a system to handle the volume of transactions we have each and every day and be stable and reliable and continue to grow to meet the needs of our organization, it was a good selection."

Mr. Restuccia said "it's going to take something pretty magical to supplant Epic." For one, there's the cost factor. The former Partners HealthCare, now Somerville, Mass.-based Mass General Brigham, paid $1.2 billion to switch to Epic in 2015, its largest investment to date of any kind.

"To change your electronic health record at this point, it's literally hundreds of millions of dollars, if not billions, and then all the change management that goes with it. So once systems like this are in place, it takes a lot to remove them," he said. "I don't know what the factor would be that would cause an institution to remove their Epic EHR at this point."

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