While Epic is meticulously working its way through the largest hospitals, the long tail of stand-alone ambulatory practices operate largely on a jumbled mess of EMRs, using many emerging vendors (such as AthenaHealth and PracticeFusion) with a multi-tenant model, similar to salesforce.com.
Since medical care as a whole is consolidating, the basic question is whether emerging EMR vendors will gain enough traction and offer enough capability to enable stand-alone practices to remain independent. Or will platform fragmentation put unaffiliated practices at such a competitive disadvantage that they'll be even more motivated to join up with larger hospital systems (the most important of which will rely upon Epic)?
What makes Epic particularly interesting is that its success seems to fly in the face of how so many of us -- Silicon Valley technologists in particular - have come to view innovation; it also contrasts with the much-celebrated, widely accepted strategy of open innovation.
"No matter who you are, most of the smartest people work for someone else," Bill Joy's law goes, and so much of the current Silicon Valley innovation ecosystem relies upon the ability to leverage the insight and wisdom of others. Let good ideas bubble up, find ways to capture creativity from everyone.
From the perspective of most technologists, Epic epitomizes the exact opposite of how a health information system should work (which is also why many of these same technologists feel it's bound to fail). Ideally, according to the technological experts, there should be a common, robust and open set of standards governing healthcare information, easing its accessibility. Companies would then compete for the most effective way to exploit the information, almost certainly via a multi-tenant platform.
According to the smartest people in the Valley, Epic shouldn't be winning. But it is. How is this possible, and what does it mean?
Epic's success suggests that it has locked onto something that its key clients - academic medical centers and large health systems -- need most right now. This burning need, it turns out, isn't the capacity for bubbled-up innovation. What they need is the quick and flawless imposition of structure - pushed down from above, and proprietary if necessary.
The tertiary hospital is a vast enterprise with incredibly complex array of care delivery, with a wide web of participating - and very vocal, idiosyncratic - stakeholders involved. It faces long-term pressures - e.g. care shifting from the hospital to ambulatory settings - and shorter-term pressures with more uncertain endpoints - e.g. reimbursement changes, regulatory requirements. They need someone to step in and define the information sharing processes for the system, providing a reliable way to capture, transport, receive, and use information, as a path towards measuring and incrementally improving the quality and efficiency of care.