An Epic voyage

Several months ago, I wrote a blog post comparing customers’ experience with Epic with the Stockholm Syndrome.

I reminded people of the syndrome:

Stockholm syndrome, or capture-bonding, is a psychological phenomenon in which hostages express empathy and have positive feelings towards their captors, sometimes to the point of defending them. These feelings are generally considered irrational in light of the danger or risk endured by the victims, who essentially mistake a lack of abuse from their captors for an act of kindness.

Then, I noted: 

What is striking about this company is the degree to which the CEO has made it clear that she is not interested in providing the capability for her system to be integrated into other medical record systems.  The company also "owns" its clients in that it determines when system upgrades are necessary and when changes in functionality will be introduced.  And yet, large hospitals sign up for the system, rationalizing that it is the best. 

I quoted an article by Kenneth Mandl and Zak Kohane in the New England Journal of Medicine:
 

We believe that EHR vendors propagate the myth that health IT is qualitatively different from industrial and consumer products in order to protect their prices and market share and block new entrants. In reality, diverse functionality needn't reside within single EHR systems, and there's a clear path toward better, safer, cheaper, and nimbler tools for managing health care's complex tasks.

A year ago, Forbes noted, "By next year 40% of the U.S. population--127 million patients--will have their medical information stored in an Epic digital record." 

It is this last point that we must now address, as I hear from my colleagues in the EHR world—no, not Epic’s competitors-- that Epic engages in practices that well help cement that market share for years to come.

They tell me, for example, there is the “good install credit.” If your enterprise chooses to have a significant portion of its IT staff trained and certified by Epic to conduct part of the system’s installation, you get a significant discount on the installation costs. On the one hand, training and using internal staff rather than outside consultants can be viewed as a good thing. On the other hand, what better way to assure future product loyalty than by indoctrinating a hospital’s internal IT force in the ways and means of this system?

Another technique they report to me is the limitation set on “certified consultants.” If you are a third-party consultant who would like to be certified as an Epic consultant, you have to promise not to work on other systems.

As a country we get nervous when any company in any sector has a market share in the range of 40% because we know that companies will use their market dominance to limit consumer options and hold back technological advancement.

In the 1980’s, we saw an antitrust case filed against the AT&T and its Bell System based on such concerns. AT&T, for example, engaged in an “installed base migration strategy,” a pricing policy that caused large business users to adopt its next generation of office-based telephone switching equipment, whether or not the users needed the new functionality. The pricing power was extraordinary. We also saw the company systematically prohibit the use of telephones and other premises-based terminal equipment provided by other manufacturers, claiming that it would damage the telephone network. You also had no choice of long distance carriers, and you paid for each call by the minute.

The situation was so pervasive that comedienne Lily Tomlin could easily generate laugh lines in her routine about Ernestine, the telephone operator, by saying, “We don't care, we don't have to...we're the phone company.”

Ultimately, the antitrust officials in the government stepped in, and the Bell System was broken up into its component parts. Competition was permitted in each segment. Anyone could install inside wire in their home or business. Anyone could manufacture and sell telephone sets. You had a choice of long distance carriers. Consumer choice expanded. Functionality increased to respond to market demand. Pricing plans changed. Value increased.

I see some analogies in the EHR environment. I hear that high-end specialty IT application companies—e.g., the best of breed emergency department system vendors—find it extremely difficult to make sales inroads in hospital systems that employ Epic, as compared to other enterprise systems. These are the folks that are developing the cutting edge applications to improve decision support, quality of documentation, and interoperability. They are the analogs to the terminal equipment, switching, and long distance companies that were squeezed out during the Bell System’s dominance.

Can we afford to delay the introduction of such systems in a health care system that is desperate for better quality and safety, greater efficiency, and higher value? While Epic does not have the market share once enjoyed by the Bell System, there is a special consideration here. We need to consider whether it is appropriate that an EHR company that is making its money in great measure on contracts paid directly or indirectly by federal funds should be able to engage in practices that support long-term market dominance.