Epic Systems (MyChart)

Transcript: (disclaimer: may contain unintentionally confusing, inaccurate and/or amusing transcription errors)
免责声明：可能包含无意中的混淆、不准确和/or 滑稽的转录错误

Ben: The answer is somewhere in the middle.
本：答案在中间某个地方。

David: Well, you texted me last night that you’ve made it to Singapore.
大卫：你昨晚发短信告诉我你已经到了新加坡。

Ben: I made it to Singapore, yes. Anytime you’re researching anything in US healthcare, you know it is time to stop your research process and start the episode once you’ve found Singapore.
Ben: 我到了新加坡，是的。在美国医疗保健领域进行任何研究时，如果你发现新加坡，就知道是时候停止研究过程，开始新的一集了。

All right, let’s do it.
好的，让我们开始。

Ben: Welcome to the Spring 2025 season of Acquired, the podcast about great companies and the stories and playbooks behind them. I’m Ben Gilbert.
本：欢迎来到《收购》2025 年春季播客，这是一档关于伟大公司及其背后的故事和策略的播客。我是本·吉尔伯特。

David: I’m David Rosenthal.
大卫：我是大卫·罗森塔尔。

Ben: And we are your hosts. Listeners, today’s episode is about a quiet company in rural Wisconsin that plays an enormous role in our lives, Epic Systems.
本：我们是你们的主持人。听众们，今天这集播客是关于一家位于威斯康星州乡村的安静公司，它在我们的生活中扮演着巨大的角色—— Epic Systems。

David: Indeed, whether you know it or not.
大卫：确实如此，无论你是否知道。

Ben: You probably know them from their medical patient software, MyChart, that, if you’re listening to this, you most likely use.
Ben: 你可能知道他们是因为他们的医疗患者软件 MyChart，如果你正在听这个，你很可能在使用它。

Epic is a very unusual company in so many ways. They do no marketing. They basically don’t do any sales, either. They often say no to potential customers who approach them. They don’t negotiate, they don’t discount. They never raised any venture capital and they’ve never done any acquisitions in their 47 years of existence.
Epic 是一家很多方面都非常不寻常的公司。他们不做市场推广。他们基本上不做销售，也不做任何谈判或打折。在他们存在了 47 年的历史中，他们从未接受过任何风险投资，也从未进行过任何收购。

They don’t work remotely. Everyone is in-person all the time. They notoriously have one gigantic campus on a farm with buildings designed to look like the land of Oz, a Wizards academy, a tree house, a barn, a replica of New York’s Grand Central Station, and an 11,000-seat auditorium underground.
他们不进行远程工作。所有人都在现场工作。他们有一个巨大的农场校区，建筑设计得像奥兹国，像巫师学院，像树屋，像谷仓，像纽约的格兰德中央火车站，还有一个地下可容纳 11,000 人的礼堂。

They have the majority of the US’ major hospital systems using their software, and of their over 600 customers, they have never lost a single one.
他们拥有美国主要医院系统的大多数用户，并且在他们的超过 600 个客户中，从未失去过任何一个。

David: That is the craziest thing to me about this company is at 47 years old, they have never lost a customer. Actually, we found out that’s not totally true. They lost one customer once for six months, and then that customer came back six months later.
大卫：让我对这家公司感到最疯狂的事情是，到了 47 岁，他们从未失去过一个客户。实际上，我们发现这并不是完全正确的。他们曾经有一名客户离开六个月，然后六个月后又回来了。

Ben: The company’s founder, Judith Faulkner, is undoubtedly one of the great founders of our time. You probably don’t know much about her or the company because the company is still privately-held, and Judy and her family foundation own about half of it.
公司的创始人朱迪·福克纳无疑是我们这个时代最伟大的创始人之一。你可能对她或这家公司不太了解，因为这家公司仍然是私人持有的，朱迪和她的家族基金会拥有该公司大约一半的股份。

Despite being large—I think at this point they’re close to $6 billion in revenue and over 14,000 employees—they have a stated goal to never go public and never be acquired. And Judith (at age 81) has created a succession plan and a trust structure for her voting shares to ensure that that will stay true forever.
尽管规模庞大——我想现在他们的收入接近 60 亿美元，员工超过 14,000 人——他们有一个明确的目标，即永远不上市，永远不被收购。81 岁的朱迪已经制定了一份继任计划和信托结构，以确保这一点永远保持不变。

David: We heard all sorts of stories about companies sniffing around Epic over the years trying to buy them. GE, Microsoft, Google, everybody you would imagine wants to buy this company, and it’s never going to happen.
大卫：多年来，我们听说有很多公司试图收购 Epic，各种各样的故事都有。通用电气、微软、谷歌，你能想到的所有公司都想收购这家公司，但这永远不会发生。

Ben: And we will dig into this at the end of the episode when we have all the context and all the numbers, but I believe that Judith Faulkner in starting one of the most valuable companies in healthcare is the most successful female entrepreneur in history.
本：而在我们拥有所有背景信息和数据细节之后，我们会在这一集的结尾深入探讨这一点，但我相信朱迪丝·法克纳创立一家在医疗保健领域最有价值的公司，是历史上最成功的女性企业家。

David: Almost undoubtedly.
大卫：几乎可以确定。

Ben: Well, all right then. Spoiler alert, listeners.
本：好吧，那我们就这样定了。剧透警告，听众们。

David: We’ll discuss that at the end.
大卫：我们会在最后讨论那个问题。

Ben: Yes. So the healthcare industry. There is so much wrong with the American healthcare system. That is an incontrovertible fact. There’s nobody that’s going to tell you, oh, actually it’s pretty good. It’s not pretty good. It’s a disaster. Runaway costs, burdens of administration, so much excess and waste causing (I think) healthcare costs are now 18% of our GDP.
Ben: 是的。所以医疗行业。美国的医疗体系有很多问题。这是一个无可争议的事实。没有人会告诉你，实际上还不错。它并不好。它是一个灾难。失控的成本，管理负担，太多的多余和浪费导致（我认为）医疗成本现在占我们 GDP 的 18%。

Rather than trying to eat that whole elephant today and unpack the entire system, today’s episode is about understanding Epic’s role within it and how Epic became so dominant.
而不是今天就试图一口吃下整个大象，全面拆解整个系统，今天的这一集是关于理解 Epic 在其中的角色以及 Epic 是如何变得如此主导的。

David: And if you want to understand the system, you have to understand Epic.
David: 要想理解这个系统，你必须了解 Epic。

Ben: Well listeners, if you want to know every time an episode drops, check out our email list. It is the only place where we will share a hint at what our next episode will be. We’ll share corrections from previous episodes, and little tidbits that we learned along the way. That’s acquired.fm/email.
本：各位听众，如果想要知道每次新一期节目上线的时间，请关注我们的邮件列表。这是我们唯一会分享下一期节目线索的地方。我们会分享之前节目的修正内容，以及我们在制作过程中学到的小知识。请访问 acquired.fm/email。

After this episode. come join Slack, talk about it with us and the entire Acquired community afterwards. I bet there are a ton of people in the medical ecosystem hanging out in the Acquired Slack. That’s acquired.fm/slack.
在这之后，请加入 Slack，和我们以及整个 Acquired 社区讨论这件事。我相信医疗生态系统中有很多人在 Acquired Slack 上闲逛。那是 acquired.fm/slack。

If you want more Acquired between each monthly episode, check out ACQ2, our interview show where we talk to founders and CEOs who are building businesses in areas that we’ve covered on the show to go a little bit deeper. Search ACQ2 in any podcast player.
如果您想了解更多收购内容，可以在每期月度节目之间查看 ACQ2，这是一档访谈节目，我们会在节目中与正在我们节目中涉及的领域建立业务的创始人和 CEO 进行深入交流。您可以在任何播客播放器中搜索 ACQ2。

As we announced last episode, we have a very fun save-the-date for you. We can’t say much yet, but after incredible listener demand over the years, we are finally coming to New York City with our friends at J.P. Morgan Payments. So July 15th, mark your calendars, and if you want to be the first to find out what we are up to, sign up at acquired.fm/nyc.
正如我们在上一集宣布的，我们有一个非常有趣的保留日期活动要送给你们。我们目前还不能透露太多，但经过多年来听众的强烈要求，我们终于要和 J.P. Morgan Payments 的朋友们一起来到纽约市。所以，请在 7 月 15 日把这个日期记在日历上，如果你想成为第一个知道我们有什么新动作的人，请在 acquired.fm/nyc 注册。

David: This is going to be…
大卫：这将是……

Ben: A night of absurdity.
本：一场荒诞的夜晚。

David: An incredible night.
大卫：一个不可思议的夜晚。

Ben: All right listeners, before we dive in, we want to briefly thank our presenting partner, J.P. Morgan Payments.
Ben: 好了各位听众，在深入讨论之前，我们想简要感谢我们的特邀合作伙伴 J.P. Morgan Payments。

David: Just like how we say every company has a story, every company’s story is powered by payments, and J.P. Morgan Payments is a part of so many of their journeys from seed to IPO and beyond.
David: 正如我们所说，每家公司都有自己的故事，而每家公司背后的故事都离不开支付，J.P. Morgan Payments 参与了众多公司的旅程，从种子轮融资到 IPO，甚至更远。

Ben: With that, this show is not investment advice. David and I may have investments in the companies that we discuss—although not Epic—and this show is for information and entertainment purposes only.
Ben: 于是，这档节目不构成投资建议。David 和我讨论的公司中可能有我们投资的——尽管不包括 Epic——这档节目仅供信息和娱乐之用。

David, take us in.
大卫，请带我们进去。

David: All right. Well, we start our journey in August, 1943 when Judy, (today) Faulkner, then Judy Greenfield, is born in Erlton, New Jersey, which is part of Cherry Hill, New Jersey, suburb of Philadelphia, right across the Delaware River, not too far from where you and I grew up.
David: 好的。我们的旅程始于 1943 年 8 月，当时 Judy（今天）福克纳，当时的名字是 Judy Greenfield，在新泽西州的埃尔顿出生，埃尔顿是费城郊区切里希尔的一部分，位于德拉瓦河对面，距离你和我成长的地方不远。

Ben: That’s true. And Taylor Swift.
本：确实。还有泰勒·斯威夫特。

David: And Taylor Swift, that’s right. Fertile ground for entrepreneurs there in the Delaware River.
David: 而泰勒·斯威夫特，没错。德拉瓦河畔是创业者的肥沃土壤。

Ben: And DuPont. So much great American entrepreneurship in that area.
Ben: 还有杜邦。美国这片土地上充满了伟大的创业精神。

David: So much indeed. And of course, I don’t think Judy really knew about all this at the time, but yes, indeed, it is a pretty auspicious time and place to be born, because just about four years later after Judy is born, just up the road a little way from Cherry Hill in Murray Hill, New Jersey, William Shockley and his colleagues would invent the transistor at Bell Labs, that would enable Microsoft, Epic, Intel, and all of this.
David: 的确如此。当然，当时朱迪可能并不了解这一切，但确实，这是一个非常有利的出生时间和地点，因为就在朱迪出生后四年，不远处的新泽西州默里山，威廉·肖克利和他的同事们在贝尔实验室发明了晶体管，这将使微软、埃 pic、英特尔等公司得以诞生。

Ben: And for a long time, the early pioneers of electronic healthcare records were hardware companies.
Ben: 有一段时间，电子健康记录的早期先驱是硬件公司。

David: Lockheed, GE, Siemens.
David: Lockheed, GE, Siemens。

Ben: Lockheed was a vendor to hospitals.
本：洛克希德是医院的供应商。

David: Incredible. But for the moment, Judy probably didn’t know anything about this because her family is not in the tech industry growing up. Her father, Lou, is a small town entrepreneur. He runs a local pharmacy and soda fountain there in Erlton called Lou’s Soda Fountain. And perhaps this is where Judy would later get her own entrepreneurial bent from.
大卫：不可思议。但当时朱迪可能对此一无所知，因为她成长的家庭并不在科技行业。她的父亲卢是一位小镇的企业家。他在埃尔顿镇经营着一家名为卢的汽水亭的药店。也许这就是朱迪后来获得自己企业家精神的来源。

Ben: Could be.  本：有可能。

David: So that’s Judy’s father. Now, Judy’s mother, Del Greenfield, was an absolute freaking dynamo. She graduated high school at age 15, and she worked first as a secretary, and then she worked with Lou at the store and pharmacy in Soda Fountain. And then later got really involved in peace advocacy during and after the Vietnam War, which I assume was not typical for her generation that lived through World War II. She ends up becoming the director of the South Jersey Peace Center.
大卫：所以这就是朱迪的父亲。现在，朱迪的母亲德尔·格林菲尔德绝对是一个超级动力源泉。她 15 岁高中毕业，最初是一名秘书，然后在汽水亭的药店和药房与卢一起工作。后来，她积极参与越南战争期间及之后的和平倡导活动，我想这在她那代经历过二战的人中是不常见的。她最终成为南新泽西和平中心的主任。

Later in life, after the kids were gone, she and Lou moved to Portland, Oregon, where Del became the executive director of an organization called Oregon Physicians for Social Responsibility, which—get this—in 1985, this group, in partnership with a broader international group called Physicians for the Prevention of Nuclear War, wins the Nobel Peace Prize. Judy Faulkner’s mom was part of a group that won the Nobel Peace Prize in 1985.
后来，在孩子们成年后，她和 Lou 搬到了俄勒冈州的波特兰，Del 成为了 Oregon Physicians for Social Responsibility 组织的执行主任，这个组织——你知道吗——在 1985 年，与一个更广泛的国际组织 Physicians for the Prevention of Nuclear War 合作，赢得了诺贝尔和平奖。Judy Faulkner 的母亲是 1985 年获得诺贝尔和平奖的团体中的一员。

Ben: Where did you find this? Because in everything that I read about Epic, and you and I basically read everything you possibly can read about Epic that’s out there on the Internet.
Ben: 你是在哪里找到的？因为在关于 Epic 的所有资料中，我和你基本上读了网上能找到的所有关于 Epic 的资料。

David: Nobody knows this.
大卫：没有人知道这个。

Ben: This is not cited anywhere, so how did you find your way to it?
本：这段内容 nowhere 引用了，所以你是怎么找到它的？

David: I was curious. I was trying to learn more about Judy’s family growing up, and I was trying to learn about the soda fountain, the pharmacy, and the impact that her dad had on her future entrepreneurial career. I started Googling obituaries and I came across her mom’s obituary where I learned this, and the company actually confirmed this to us. Yes, Judy’s mom won and shared the Nobel Peace Prize in 1985. Incredible.
大卫：我很好奇，想了解更多关于朱迪成长的家庭情况，还想了解那个冷饮柜台、药房以及她父亲对她未来创业生涯的影响。我开始在网上搜索讣告，然后在她母亲的讣告中发现了这些信息，而且公司也证实了这一点。是的，朱迪的母亲在 1985 年赢得了并分享了诺贝尔和平奖。真是令人难以置信。

Ben: So cool. All right, so you’ve got entrepreneurial DNA, you’ve got peace-oriented, divergent-thinking DNA.
本：太酷了。所以你有创业者的基因，还有和平主义、发散思维的基因。

David: Then you’ve got Judy, and at this point in time growing up, she’s mostly just interested in math. She loves to tell the story about how when she was in seventh grade, a teacher asked the class a number theory problem.
David: 然后有朱迪，而在这个成长阶段，她主要对数学感兴趣。她喜欢讲述她在七年级时的一个故事，当时一位老师问了班级一个数论问题。

Of course, probably didn’t frame it as a number theory problem, but asked the class, why is it that numbers that are divisible by three, if you add up all the digits of that number, that number that is the sum of its digits is also divisible by three? This is like a law of number theory. Judy hears this problem and she’s just like, my future is in math.
当然，可能没有把它框定为一个数论问题，而是问班级里，为什么能被三整除的数，将这个数的各位数字相加得到的和也一定能被三整除？这就像数论的一个定律。朱迪听到这个问题后，心想，我的未来在数学。

So in 1961, Judy graduates high school. She goes to Dickinson College to major in math. While she’s there, she gets a summer job one year at the University of Rochester, just a little bit farther north, in their particle physics lab.
1961 年，朱迪高中毕业。她进入迪金森学院主修数学。在那里，她有一年夏天在位于北面不远处的罗切斯特大学的粒子物理实验室工作。

For the work that she had to do over the summer, she needed to learn computer programming. This is in the early mid-60s. You got to learn Fortran for the work that we’re doing here and running these experiments over the summer.
为了她在暑假里要做的工作，她需要学习计算机编程。这大约是在 20 世纪 60 年代中期。我们需要学习 Fortran 来进行这里的实验并在暑假里运行这些实验。

They give her a book, a manual on Fortran, Judy teaches herself Fortan in a week, and becomes one of the best programmers in the lab. If you’re not getting the picture here, Judy is a genius. She’s an incredibly talented person.
她们给了她一本书，一本关于 Fortran 的手册，朱迪在一周内自学了 Fortran，并成为了实验室里最好的程序员之一。如果你还不明白这里的意思，朱迪是个天才。她是一个极具天赋的人。

Ben: And programming at a time when programming wasn’t a thing. The field of software engineering was not a field. These are math people taking programming languages and using them, but there are very few of those people in the world.
Ben: 而且是在编程还不是一个行业的时代。软件工程领域根本就不存在。这些是数学人才在使用编程语言，但世界上这样的人才非常少。

David: Universities didn’t have computer science departments until this point in time. Judy is intertwined with the beginning of computer science as a field.
大卫：在此之前，大学里还没有计算机科学系。朱迪与计算机科学这一领域的开端紧密相连。

Ben: Makes sense.  本：有道理。

David: So she absolutely falls in love with programming that summer in Rochester. She’d later say that she felt like a kid playing with clay, and that programming a computer was like this amazing combination of math, which of course she loved, but it was also language and art together with math.
大卫说：“她那个夏天在罗切斯特完全爱上了编程。她后来曾说，编程的感觉就像一个孩子玩黏土，而编程计算机就像是数学、她当然喜欢的学科，还有语言和艺术的完美结合。”

Ben: She has an artistic side, too. For as math-y as she is, she also has a hyper creative streak.
Ben: 她也有艺术的一面。尽管她非常擅长数学，但也有一股超乎寻常的创造力。

David: Obviously, her story is very different and she is a very different person than him, but the echoes that you’re seeing here in Judy in what she’s exposed to as a kid, how she thinks, how she operates as an entrepreneur, you should be getting some Bill Gates vibes here.
大卫：显然，她的故事非常不同，她也与他截然不同，但在朱迪身上你所看到的回声，她在小时候所接触到的东西，她的思维方式，以及她作为企业家的运作方式，你应该能感受到一些比尔·盖茨的气息。

Ben: I thought you were going to say Steve Jobs with the peace time orientation, around her upbringing, and the, I don’t want to say hippie for Judy, but almost hippie-esque movement too.
Ben: 我以为你会提到史蒂夫·乔布斯在和平时期的倾向，以及她的成长背景，虽然我不愿用嬉皮士来形容朱迪，但那种嬉皮士般的感觉也是有的。

David: That’s actually a good point. Well, Jobs and Gates. Well, the reason I said Gates is to foreshadow some Microsofty and DNA and analogies that come into Epic here.
大卫：这其实是一个很好的观点。嗯，乔布斯和盖茨。我说到盖茨是为了预示一些与微软、DNA 和类比相关的内容会出现在 Epic 这里。

Ben: And they’re contemporaries. She is going to build her company in almost the exact same timeframe that Apple and Microsoft were built.
Ben: 而且他们是 contemporaries。她将在几乎与苹果和微软相同的时间框架内建立她的公司。

David: Totally. So when Judy gets back to Dickinson, to college, she decides that she’s going to apply to grad schools in math. She applies to five PhD programs. She of course gets into all of them. On her CV, she lists her Rochester experience and her Fortran programming experience.
大卫：完全如此。所以当朱迪回到迪金森学院时，她决定申请数学研究生院。她申请了五个博士项目。当然，她被所有这些项目录取了。在她的简历上，她列出了罗切斯特的经历和她的 Fortran 编程经验。

Two of the schools she applied to, Stanford and the University of Wisconsin, are just starting their computer science departments. When she applied, they didn’t have computer science departments, and in the interim they started them. They saw Judy’s application.
她申请的两所学校斯坦福和威斯康星大学刚刚开始设立计算机科学系。她在申请时，这两所学校还没有计算机科学系，后来在她申请期间建立了这些系。他们看到了朱迪的申请。

Obviously, this is a brilliant person who we want here at the university. We’re starting these CS departments. They unilaterally shift her applications to their new CS schools. Judy’s like, oh, I didn’t even realize I could go get a PhD in computer science. Amazing. This is what I’m going to do.
显然，这是一位杰出的人才，我们希望她能加入大学。我们正在成立这些计算机科学系。他们单方面将她的申请转到他们新的计算机科学学校。朱迪说，哦，原来我可以申请计算机科学的博士学位。太棒了。这就是我要做的。

She ends up choosing Wisconsin, goes off to Madison, Wisconsin to start her PhD in computer science, which as we shall see, she never finishes, but she also never leaves. What a sliding door moment. If Judy had gone to Stanford instead, we would probably still be telling this story about her, but it would be a very different story.
她最终选择了威斯康星州，去了威斯康星州的麦迪逊开始她的计算机科学博士课程，正如我们将要看到的，她从未完成这个课程，但她也从未离开。多神奇的一个“关门”时刻。如果朱迪去了斯坦福大学，我们可能仍然会讲述她的故事，但那将是一个非常不同的故事。

Ben: For sure. She would’ve been indoctrinated by a very different type of DNA, what computers are for, and what types of companies you should be building with computers if she was in Silicon Valley at that point.
Ben: 没错。如果她在那时身处硅谷，她的思想会被完全不同类型的 DNA 所熏陶，了解计算机的作用，以及应该用计算机构建什么样的公司。

David: While she’s at Wisconsin, Judy takes a class called Computers in Medicine, taught by a faculty member from the Wisconsin Medical School named Dr. Warner Slack. This is probably the first course of its kind anywhere in the world. Computer science departments themselves are new. The idea of applying computer science and computers to the practice of medicine is new.
杰 udy 在威斯康星大学学习一门叫做医学中的计算机的课程，这门课是由威斯康星医学院的一位教授 Dr. Warner Slack 讲的。这可能是世界上第一门此类课程。计算机科学系本身也是新的。将计算机科学和计算机应用于医学实践是一个新的想法。

Ben: It had to be one of the first classes of its kind because mainframes were really becoming a thing in the 60s, period. I think ENIAC was only 15–20 years before.
这门课程可能是世界上第一批此类课程之一，因为大型机在 60 年代开始变得流行。我认为 ENIAC 出现的时间大约比这早 15 到 20 年。

David: It’s a good point. This is the first time anybody could use computers for anything outside of government and the defense industry.
这是一个好观点。这是人们第一次能够将计算机用于政府和国防工业之外的任何事情。

So Judy takes this class from Dr. Warner Slack, and as you might expect, she’s the star student in the class. Afterwards, Dr. Slack asks her to work on writing a program for use in the hospital, in the medical school, to optimize the on-call schedules for doctors. Doctors have to have on-call schedules, so optimizing that, perfect thing that a computer application could do.
所以朱迪从温纳·斯莱克医生那里上这门课，正如你所预料的，她是班上的明星学生。之后，斯莱克医生让她负责编写一个用于医院和医学院的程序，以优化医生的值班安排。医生必须有值班安排，所以优化这一点，正是计算机应用程序可以做到的完美事情。

Judy says, yes, great. She starts working on it. This is a part-time job for her as a grad student. She’s getting paid $5 an hour for her programming time, trading time for money here.
Judy 说，好的，很好。她开始着手做这件事。这是一份兼职工作，她是作为研究生做的。她每小时获得 5 美元的编程报酬，用时间换钱。

Apparently, the story goes that her programming was so good and she was so efficient at writing these applications because she would go on lots of departments and the hospital would ask her to write various applications for them, that she actually didn’t make that much money because she just wrote them so fast and she was getting paid by the hour. They gave her a raise at one point. They doubled her salary to $10 an hour and still didn’t make that much.
据说，她的编程非常好，写这些应用程序也非常高效，因为她会去很多部门，医院也会请她为他们编写各种应用程序。因此，她实际上并没有赚很多钱，因为她写得非常快，而且是按小时计酬。他们曾经给她加薪，将她的工资提高到每小时 10 美元，但仍然赚得不多。

Anyway, as she’s going around throughout the Wisconsin Medical Department—she’s working with psychiatry, OB-GYN, rehab, in-patient in the hospital, and the intensive care unit—she starts to get these requests from all the different doctors and the different practices.
无论如何，她在整个威斯康星州医疗部门巡视时——她与精神科、妇产科、康复科、医院的住院部以及重症监护室合作——开始收到来自各个医生和不同诊所的这些请求。

A big problem we have is we’re seeing these patients, other departments are also seeing the same patients, but there’s no way for us to know what’s happening to those patients in other departments across the hospital as they’re being seen. We really would love it if there was a single database that could keep records on every patient that we have across the whole longitudinal course of their care here at the University of Wisconsin Medical Center. An electronic health record for these patients, you might say. And this is the origin of Epic.
我们面临的一个大问题是，我们在看诊这些患者，其他部门也在看诊同样的患者，但我们无法知道这些患者在医院其他部门的诊疗情况。如果我们有一个单一的数据库，能够记录我们在威斯康星大学医学中心为每位患者在整个治疗过程中的所有记录，那该多好。为这些患者建立一个电子健康记录，就是这个想法的起源。Epic 就是这样诞生的。

But before we go further on what Judy does next, I think it’s worth taking a step back and talking about what are health records, what are medical records, what was the state of them in America here in the mid-60s, and why is this idea of an electronic version of them so appealing?
但在我们进一步讨论朱迪接下来的做法之前，我认为有必要退一步谈谈什么是健康记录，什么是医疗记录，它们在 20 世纪 60 年代中期的美国是什么状态，以及为什么电子版本的想法如此吸引人？

Patient health records, at least here in the American medical system, were a ragtag informal process, and they were all paper-based, of course.
患者健康记录，至少在美国医疗系统中，是一个杂乱无章的非正式过程，当然都是纸质的。

Ben: And I think they had dated back to attempts at unifying them or creating standards all the way until 1912.
本：我想这些可以追溯到试图统一它们或创建标准的努力，一直持续到 1912 年。

David: Yes, at Mass General, so all of the efforts to standardize them. You can imagine all the reasons why standardizing them is important. Patients see different doctors at different hospitals and they move. Even within a hospital like here at the University of Wisconsin, cardiology really wants to know what has happened to this patient in other departments that they’ve been in before, et cetera.
David：是的，在麻省总医院，所以所有的努力都是为了标准化它们。你可以想象标准化它们的重要性。病人在不同的医院看不同的医生，并且他们可能会搬家。即使是在像威斯康星大学这样的医院内部，心脏病学真的想知道这个病人在之前去过其他部门发生了什么，等等。

Ben: Or if you have to see a different doctor for the same thing, it’d be great if they’re calling the same condition the same condition.
Ben: 或者如果你因为同样的问题需要看不同的医生，如果他们把同样的情况称为同样的情况那就太好了。

David: Exactly. All of the efforts around standardization in the country really go back to Massachusetts General Hospital in Boston, which Mass Gen or MGH is the main and largest teaching hospital of Harvard Medical School. It would make sense that this is where a lot of research is happening.
David: 没错。国家在标准化方面所做的所有努力都可以追溯到波士顿的麻省综合医院，即 MGH 或麻省总医院，它是哈佛医学院的主要和最大的教学医院。这确实是一个很多研究正在进行的地方。

Like you said, in 1912 a few members of the American Medical Association and the American Hospital Association get together there at Mass General in Boston, and they start working on can we create some standard entry practices for physicians that we can distribute across the country, that physicians can use as their patient diaries as they’re known back in the day.
就像你说的，1912 年，美国医学协会和美国医院协会的几名成员在波士顿的麻省总医院聚在一起，他们开始着手制定一些标准的医疗记录流程，这些流程可以在全国范围内分发，供医生们作为患者的病历使用（当时称为患者的日记）。

So in 1919—it takes them seven years to do this—they did finally introduce a standardized “treatment diary” for distribution across the country. Now, there’s no incentive for doctors to actually use this, and doctors (as we shall see) are notoriously an independent-minded group and profession and don’t like being told what to do or how to design the notes that they take.
所以早在 1919 年——他们花了七年时间才做到这一点——他们终于推出了一个标准化的“治疗日记”，在全国范围内推广。然而，医生并没有动力去实际使用这个系统，而医生（正如我们将看到的）是一个以独立著称的群体和职业，他们不喜欢别人告诉他们该怎么做，也不喜欢别人设计他们记录的内容。

Ben: Which makes sense. They’ve been the smartest people their whole life. They’re doing this thing that requires an incredible amount of education. It’s a very prestigious, high paying job.
Ben: 这很有道理。他们一生都是最聪明的人。他们正在做一件需要极高水平教育的事情。这是一份非常有声望、高薪的工作。

David: And I think there’s a good argument for this here, too. The practice of medicine, especially then and still now, is equal parts art and science. Telling me how to standardize what is going on with my patient, probably seemed anathema at the time.
大卫：这里也有很好的理由。医学实践，尤其是过去和现在，既是艺术也是科学。告诉我如何标准化我患者的状况，当时可能被认为是不可接受的。

Ben: I’m the doctor. I know best. I’ll figure out what delivers the best care.
Ben: 我是医生，我知道最好。我会 figure out 最好的护理方式。

David: Exactly. This continues for a while. Then finally in 1928, the Association of Health Record Librarians of North America gets set up as an official body to standardize collection, storage, retrieval of patient data. This is a fun callback. I believe the Rockefeller Foundation was behind funding all this, call back to our Standard Oil episodes.
David：正是。这种情况持续了一段时间。然后终于在 1928 年，北美健康记录图书馆协会作为一个官方机构成立，以标准化患者数据的收集、存储和检索。这是一个有趣的回溯。我相信洛克菲勒基金会资助了这一切，回溯到我们的标准石油时期。

Ben: I believe that because wasn’t our conclusion on Standard Oil, that the Rockefeller Foundation is the initial funder of the nation’s medical schools?
Ben: 我认为，因为我们不是在标准石油案中得出的结论，罗克菲勒基金会是否是国家医学院的最初出资方？

David: Yes.   大卫：是的。

Ben: Or kicked off the movement of having real medical schools.
Ben: 或者启动了真正医学学校的运动。

David: One of, if not, maybe the main goal of the Rockefeller Foundation was to improve the state of medical care in America. It makes total sense that, oh, here in the late-20s, early-30s, this is getting funded by them.
大卫：如果不算主要目标的话，洛克菲勒基金会的主要目标之一可能是改善美国的医疗保健状况。在 20 年代末到 30 年代初，这由他们资助完全合乎情理。

So all this is great. But the reality is, until this time in the 1960s when computers start to arrive, even the best intentions that even (let’s say) doctors really want to follow all this, as long as you’re dealing with paper records, there’s a limit of how helpful this can all be.
所以这一切都很好。但现实是，在 20 世纪 60 年代计算机开始出现之前，即使医生们真的希望遵循这一切，只要你还处理的是纸质记录，这一切的帮助也就有限了。

You could standardize it as much as you want, but you still have to get the reams of paper from one physical location in a hospital to another. God forbid you’re trying to get to a different hospital or a different health system or a different state. It’s a mess.
你可以尽可能地标准化，但你仍然需要将一沓沓纸从医院的一个物理位置移到另一个位置。更糟糕的是，如果你需要把文件送到不同的医院、不同的医疗系统或不同的州，那简直是一团糟。

Ben: Not to mention paper doesn’t lend itself well to structuring data, because at the end of the day, you can write on paper however you’d like to.
本：而且纸张并不适合结构化数据，因为最终你可以随意在纸上书写。

David: We finally get to the current moment in time that we’re here in the mid-1960s, and two really important things happen. You can argue that they’re both of equal importance.
大卫：我们现在终于来到了 1960 年代中期的时间点，发生了两件非常重要的事情。你可以认为这两件事情同样重要。

One, the arrival of the computer age. You can now digitize this stuff. It’s possible to have portability and standardization, and the dream can really be realized here. The other maybe more important thing that happens is in 1965, Congress creates Social Security, Medicare, and state-based Medicaid programs in America.
一个是计算机时代的到来。现在可以将这些内容数字化。可以实现便携性和标准化，这里的梦想真的可以实现。另一个可能更为重要的事情发生在 1965 年，国会创建了社会保障、医疗保险以及各州基于的医疗补助计划。

Ben: Ah yes. So we have so far given you the technological history of medical records, and now it’s time to flip over to the policy side of things, which in medicine you have to understand policy before you can understand the business. All business structure in this industry is driven by what is the architecture of policy in America. We rewind the clock again to 1942.
Ben: 噢对了。到目前为止，我们已经给你讲述了医疗记录的技术历史，现在是时候转向政策方面了，在医学领域，你必须先理解政策才能理解商业。这个行业中的所有商业结构都由美国的政策架构驱动。我们再次将时间倒回到 1942 年。

David: Oh, all right. Educate me here.
大卫：好的，这里给我教育一下。

Ben: We’re going to catch up to Medicare here. In 1942, America is at war. There is something passed called the Stabilization Act that imposed wage and price controls. An interesting thing to note, at this point in time, only 10% of Americans have health insurance, period.
本：我们将在医疗保健方面赶上医疗保险。1942 年，美国正处于战争状态。当时有一项被称为《稳定法案》的法律，实施了工资和价格控制。值得注意的是，在这个时期，只有 10%的美国人有健康保险。

David: Mostly, the paradigm in healthcare is you pay for service. You go to the doctor, you pay the doctor.
大卫：医疗行业的范式主要是你付费服务。你去看医生，就付给医生费用。

Ben: You don’t yet have these runaway costs and well, I might have a procedure that could randomly cost a million dollars. You don’t yet have these amazing breakthrough treatments that could be very expensive if you were able to achieve them, so you mostly just paid out of pocket.
Ben: 你还未面临这些失控的成本问题，而且，我可能有一个随机成本高达一百万美元的程序。你还未拥有那些令人惊叹的突破性治疗方法，如果能够实现它们可能会非常昂贵，所以你主要还是自费支付。

You’ve got these wage controls, but employers still want to be able to attract top talent, so the way around the wage controls was to offer health insurance as a bonus to work around the system.
你有这些工资控制，但雇主仍然希望吸引顶尖人才，所以绕过工资控制的方法是提供健康保险作为额外福利来绕过系统。

David: Markets always find a way.
大卫：市场总有办法。

Ben: As soon as this happens, unions go, oh, this is awesome. Our people can make more money. Amazing.
Ben: 一发生这种情况，工会就会说，哦，太棒了。我们的员工可以赚更多的钱。太 amazing 了。

David: We’re going to make capital pay for our health plans now, yeah.
大卫：我们现在要让资本为我们的健康计划买单，是的。

Ben: Exactly. Increased wages for workers. This is what we’re all about. They lobby to make it explicitly legal since it was a gray area from the wage controls. So the National War Labor Board makes it official. You can do this.
恰当。为工人增加工资。这就是我们要做的。他们游说使其在法律上明确合法，因为工资控制存在灰色地带。所以全国战争劳工委员会正式做出了这一决定。你可以这样做。

Two, employers and the health insurance companies that are springing up then lobby to say, hey, these health insurance premiums, can we make these tax deductible for the business? Because the business shouldn’t have to pay taxes on this money if they’re going out and buying health plans for their employees with it.
两家雇主和随后出现的健康保险公司游说，说：嘿，这些健康保险费用，我们能否将这些费用列为可抵扣税项的支出？因为如果公司用这笔钱为员工购买健康计划，那么公司不应该对这笔钱缴税。

On top of that, even though it’s a form of compensation, can we make that not taxable as income? That would be really great. The businesses can deduct it and the individuals shouldn’t have it affect their income taxes, even though clearly compensation.
除此之外，虽然这是一种补偿形式，我们能否让它不计入收入征税？这将非常好。企业可以抵扣这部分费用，而个人不应因这被视为补偿而影响其所得税。

David: This is where the whole origin of pre-tax stuff versus post-tax stuff in your paycheck comes from.
大卫：这就是你在工资中看到的预扣税和后扣税内容的由来。

Ben: Exactly, so this sets it all in motion. With incentives like that, why would you want your healthcare any other way? What a dream. You can pay for your premiums with pre-tax dollars. And what a dream for employers that can now offer this benefit that was deductible.
本：正是这样，这就一切都开始了。有了这样的激励措施，你为什么还会希望你的医疗保健有任何其他方式呢？这简直是一个梦想。你可以用预扣税的款项支付保险费。这对于现在可以提供这项可抵扣税的福利的雇主来说，也是一个梦想。

At the end of the war in 1946, the percentage of Americans who had medical insurance was already up to 30% from that 10% number just 6 years before. Flash forward a couple of decades, 1964, it’s now up to 80%.
在 1946 年战争结束时，拥有医疗保险的美国人比例已经从 6 年前的 10%上升到 30%。再快进几十年，1964 年，这一比例已经上升到 80%。

Of course it was going to run the table and become the default as soon as this regulatory framework was set up. Once we did this, the US did not have a chance of implementing any other system. We were just going to end up with employers primarily being responsible for health insurance and creating large insurance companies to provide it.
当然，一旦建立了这个监管框架，它就会一统天下并成为默认系统。一旦我们这样做，美国就没有任何机会实施其他系统。最终，雇主将主要负责健康保险，并建立大型保险公司来提供这些保险。

David: That takes us to 1965 and Medicare and Medicaid, because the big policy question is now what do you do about all the people who don’t have jobs?
大卫：这带我们来到了 1965 年，以及医疗保险和医疗补助，因为现在大的政策问题是，你将如何对待那些没有工作的人？

Ben: What do you do about people who don’t have jobs, which actually aren’t that many, but what do you do about people who are old or poor? America needs a social safety net. That’s what we’re all about.
Ben: 没有工作的人你怎么办，虽然这样的人其实并不多，但你怎么办那些年纪大或贫穷的人？美国需要一个社会安全网。这就是我们要做的事情。

David: Who also, by the way, are the highest consumers of healthcare.
大卫：顺便说一句，他们也是医疗保健的最大消费者。

Ben: So here we are in 1965. David, you’re exactly right. Medicare and Medicaid enter the picture as a part of the Social Security Act. How did we get here is interesting.
本：所以我们来到了 1965 年。大卫，你说得没错。医疗补助和医疗救助作为社会保障法的一部分进入了我们的视野。我们是如何走到这一步的很有趣。

FDR, Truman, and Kennedy had all tried to pass a single payer system the way that the UK did right after World War II. The UK is in this moment of great nationalistic pride. We all have to band together, look after one another. They pass the National Health System.
FDR、杜鲁门和肯尼迪都曾试图在二战后像英国那样推行单 payer 系统。当时的英国正处于民族自豪感强烈的时刻。我们必须团结起来，互相照顾。他们通过了国民健康服务系统。

The US does not have the political will to do it, so we don’t. You have this coverage gap, to your point earlier, of all these people who are not currently in the workforce. The compromise is we will create Medicare for those over 65 and Medicaid if you have a low income or other special situations. We can’t really fund either exactly right, so we’ll figure out how to fund Medicare out of the Federal government, and Medicaid, let’s make that the state’s responsibility. We’ll help, but we’ll federate that out to the states.
美国没有政治意愿去做这件事，所以我们也不做。正如你之前提到的，存在这个覆盖缺口，即所有目前不在劳动力市场的人。妥协方案是，我们将为 65 岁以上的老人创建医疗保险，为低收入或其他特殊情况下的人创建医疗补助。我们无法完全资助这两者，所以我们将想办法通过联邦政府来资助医疗保险，而医疗补助则让各州负责。我们会提供帮助，但会将这一责任分发给各州。

So all of that is our system today. Private insurers, you have a job buying directly from the CA. If you don’t, but again, still from private insurers, Medicare or Medicaid if you fall outside those buckets.
所以这就是我们今天的系统。私人保险公司，你们需要直接从 CA 购买。如果不这样做，但仍然来自私人保险公司、 Medicare 或 Medicaid，如果你不符合那些类别。

The important thing to realize from all this is that the vast majority of patients do not feel the cost of their healthcare directly in the United States. Those costs are so laundered through private insurance companies and Medicare and Medicaid, that most people think about any given health encounter as being paid for by someone else, by a part of some system.
从所有这些可以看出，绝大多数患者在美国并不直接感受到其医疗保健的成本。这些成本是通过私人保险公司、医疗保险和医疗补助等渠道进行“洗钱”的，因此大多数人会认为任何一次医疗接触都是由系统中的某个部分支付的。

If you’re trying to unpack how did our healthcare become 18% of GDP versus 11% of the UK GDP or a staggering 6% of Singapore’s GDP, albeit at a much smaller scale, why are we 18%? A big thing you have to understand is psychologically every healthcare encounter is that the system is paying for it. I’m paying into the system, the system is paying for it, but what does it cost? What do I actually pay? It’s a big abstraction.
如果你试图理解为什么我们的医疗保健开支占 GDP 的 18%，而英国仅为 11%，新加坡更是低至 6%（尽管规模较小），我们为什么是 18%？你需要理解的一个重要心理因素是，每次医疗保健遭遇时，系统都在为此买单。我为系统贡献，系统为我买单，但实际成本是多少？我到底付出了多少？这是一个很大的抽象概念。

David: In case it’s not glaringly obvious, why is this so important to medical records and the fledgling electronic medical record industry here? Because now, with these second- and third-party payers set up, you need documentation of what happened in order to get paid.
David: 除非非常明显，否则为什么这对医疗记录以及这里新兴的电子医疗记录行业如此重要？因为现在，有了这些第二方和第三方支付者，你需要记录下发生了什么才能得到付款。

If you’re a hospital or you’re a doctor or you’re a clinical practice before this system, you just see your patients and they pay you. Now, after this system, you see your patients and then you need to negotiate with the payer, whether that’s the insurance company or the government about getting paid for that. The insurance companies and the government, they’re like, well, hey, I need proof. I need documentation of what you did. I’m not going to pay you if you just tell me that you did this stuff.
如果你是一名医院、医生或是在此系统之前的一家临床实践机构，你只需要看你的病人并获得他们的付款。现在有了这个系统，你不仅要看病人，还需要与付款方（无论是保险公司还是政府）进行谈判，以获得付款。保险公司和政府会说，嘿，我需要证据。我需要你所做工作的文件证明。如果只是告诉我你做了这些事情，我是不会付款的。

Ben: And I need it in a really standardized form.
Ben: 我需要它以一种非常标准的形式。

David: I need an official standardized medical record. All of a sudden you start this Faustian bargain or slippery slope (if you will) for the medical profession of okay, in order to get paid and get paid more and more over time, as my procedures that I’m doing become more and more complex, I need strictly codified, regulated, and standardized documentation of what I did. I need really bulletproof workflows and data flows between what’s happening in the patient room and then what bills get sent over to the payers.
大卫：我需要一个正式的标准医疗记录。突然之间，你们开始了一场福斯达特契约或滑坡（如果你愿意的话）对于医疗行业的交易，即为了获得报酬，并随着时间的推移不断增加报酬，因为我的手术变得越来越复杂，我需要严格编码、监管和标准化的记录我做了什么。我需要非常可靠的流程和数据流，从患者房间发生的情况到随后的账单被发送给支付方。

Thus the existential need for an electronic medical record system. But really also, and maybe more importantly, an electronic medical billing system.
因此，迫切需要一个电子医疗记录系统。但更重要的是，一个电子医疗计费系统。

Ben: And the realization that I think the whole industry had early is insurance wants to pull together in a very large pool, so the payers are always going to have a tremendous amount of leverage over individual physicians, small hospital systems, even larger hospital systems. You really need to be extremely buttoned up, extremely standardized, and extremely auditable, because you’re negotiating with this large counterparty, whatever the given payer is, be it a government or a large insurance company, that’s going to have leverage over you.
本：而行业早期意识到的一个现实是，保险公司希望将大量资金汇集到一个大池子里，因此支付方总是能够在个体医生、小型医院系统，甚至是大型医院系统面前拥有巨大的杠杆作用。你真的需要非常严谨、非常标准化，并且非常可审计，因为你需要与这个大型对手方进行谈判，无论给定的支付方是政府还是大型保险公司，他们都会对你有杠杆作用。

David: And for the hospitals, in terms of “customers”—I mean, they’re not customers, they’re payers; the reason they’re called payers is they’re not getting the delivery of care, they’re just paying for it—of that set of payers, Medicare and Medicaid are the big gorillas, because they’re covering the elderly population who are consuming the vast majority of care, the vast majority of complicated care, and expensive care in the country.
大卫：而对于医院来说，从“客户”的角度来看——当然，他们不是客户，而是付款人；称他们为付款人是因为他们并没有提供医疗服务，只是支付费用——在这组付款人中，医疗保险和医疗补助是主要的“大个子”，因为它们覆盖了消费了国家绝大多数医疗服务、绝大多数复杂医疗服务和昂贵医疗服务的老年群体。

Ben: Makes sense.  本：有道理。

David: Here we are in 1966, the year after Medicare and Medicaid get created by the government. There’s this existential reason now for healthcare to adopt systematized records.
大卫：我们现在是 1966 年，医疗保险和医疗救助在政府的推动下刚刚创立。现在医疗保健有了采用系统化记录的生存性理由。

A group, once again at Massachusetts General Hospital in Boston, starts work on the first real computerized medical records system called COSTAR (COmputer STored Ambulatory Record). It’s used for patient scheduling, registration, clinical data and everything you would think of in an electronic health record, but also critically, billing and interfacing here with the payers. Development for that was funded by the National Institute of Health.
一个小组再次在波士顿的麻省总医院开始工作，开发第一个真正的计算机化医疗记录系统，名为 COSTAR（COmputer STored Ambulatory Record）。该系统用于患者预约、注册、临床数据以及电子健康记录中你能想到的所有内容，但更重要的是，用于计费和与支付方的接口。该系统的开发得到了国家卫生研究院的资助。

The technical requirements for creating this, though, are actually pretty difficult, especially with programming languages available at the time, like Fortran or whatnot. This is a very high concurrency transaction system. A lot of users need to use this across a health system.
创建这些技术要求其实相当困难，尤其是在当时可用的编程语言（如 Fortran 等）的情况下。这是一个非常高并发的交易系统。很多用户需要在医疗系统中使用它。

Ben: Even then.  本：即便如此。

David: Even then, yeah. A lot of users across a health system need to use this and it needs to interface with a lot of endpoints, and especially with the limited storage and processing power of computers like mainframes at the time. The group of programmers that were working on this found that existing programming languages couldn’t really suit their needs to build what they needed, so they end up writing their own new programming language called the Massachusetts General Hospital Utility Multi Programming System, or MUMPS.
David: 即使在那时，也需要很多用户在一个医疗系统中使用这个系统，并且它需要与很多终端接口，尤其是当时的大型机等计算机存储和处理能力有限的情况下。负责这个项目的程序员们发现现有的编程语言无法满足他们的需求来构建他们需要的东西，因此他们最终编写了自己的新编程语言，称为马萨诸塞总医院实用多编程系统，或 MUMPS。

Ben: Which is amazing that there’s a medical-oriented programming language called MUMPS.
Ben: 真是太神奇了，竟然有一种面向医疗的编程语言叫 MUMPS。

David: And Epic still uses MUMPS today, or actually it uses its modern descent in Caché, but this is the standard programming language and database system for the industry.
David: 而 Epic 今天仍然在使用 MUMPS，或者说它使用的是 MUMPS 的现代衍生版本 Caché，但这已经是该行业的标准编程语言和数据库系统了。

Ben: I don’t know about the industry, but for Epic, which I guess now for the industry.
本：我不知道整个行业的状况，但就 Epic 而言，我想现在它已经代表了整个行业。

David: Well that’s what I was going to say. Many of Epic’s competitors do not use this, but Epic does, so it’s de facto the standard now.
大卫：好吧，这就是我想说的。许多 Epic 的竞争对手不使用这个功能，但 Epic 使用了，所以现在它实际上成了标准。

Now there are two key features of MUMPS, and this is why these programmers had to create their own language. One, the language and the database are integrated. Right there within the programming language is a database structure. That makes it very computationally-efficient for handling all these high velocity and data-intensive transactions that need to happen.
现在 MUMPS 有两个关键特性，这也是这些程序员不得不创建自己语言的原因。一是语言和数据库是集成的。编程语言中就包含了一个数据库结构。这使得它在处理所有这些高频率和数据密集型交易时非常计算高效。

Ben: Or at least efficient for the programmer, because you’re not switching over the right SQL queries in the middle of your program. Everything is in the same language. If what you’re doing is primarily building a wrapper around a database, to use modern parlance, a glorified database that is going to constantly be read and written to, kind of nice for it to all just be one standard language.
Ben: 或者至少对程序员来说是高效的，因为你不需要在程序中间切换不同的 SQL 查询。一切都是同一种语言。如果你主要是在构建一个数据库的封装层，用现代的说法，就是一个被频繁读写的高度封装化的数据库，那么所有东西都用同一种标准语言会很好。

David: The other thing that they design it for is for multiple simultaneous users. Imagine you’ve got different departments within a hospital updating the same patient record at the same time. You’ve got then administrators in the hospital also updating that record to know what’s been billed out to a payer, what’s not been, what’s been challenged, et cetera.
大卫：他们设计它还考虑到多个同时用户的需求。想象一下，在一家医院内，不同的部门在同一时间更新同一个病人的病历记录。然后医院的管理员也在更新这个记录，了解已经向保险公司收费的项目、未收费的项目以及被质疑的项目等等。

Ben: You don’t want collisions to create data loss or something like that. This is people’s lives we’re dealing with.
Ben: 你不希望碰撞导致数据丢失之类的问题。我们处理的是人们的生活。

David: Exactly. Now the lead programmer of this group here at MGH, at Mass Gen, that is creating COSTAR and MUMPS, was a recent MIT graduate named Neil Pappalardo. Being the young enterprising MIT grad that he is, a couple of years later in 1968, Neil spins out and starts a company around this to sell his software, originally called Medical Information Technology, or MIT.
David: 恰当。现在，这里在麻省总医院（MGH）领导这个小组的首席程序员，正在开发 COSTAR 和 MUMPS 的，是一位名叫尼尔·帕帕拉多的近期麻省理工学院毕业生。作为年轻的有进取心的麻省理工毕业生，几年后，即 1968 年，尼尔创立了一家公司来销售他的软件，最初名为医疗信息技术，或简称 MIT。

Ben: Name’s taken.  Ben: 名已占用。

David: Hey. But soon he changes the name perhaps at the request of the real MIT to Meditech. For folks in the industry, that’ll sound very familiar because Meditech is still in business today and is the number three player in the EMR space behind Epic and Cerner.
David: 嗨。但很快他可能应麻省理工学院的要求将名称改为 Meditech。对于行业人士来说，这听起来非常熟悉，因为 Meditech 至今仍在运营，并且是 EMR 领域仅次于 Epic 和 Cerner 的第三大玩家。

Ben: Pretty amazing.  本：真是令人 amazed。

David: Back to Judy now here at the University of Wisconsin. She’s working with Dr. Slack and the medical department there doing all these various application projects. Then Dr. Slack moves to Harvard where he of course meets Neil and starts working with Meditech. But he and Judy keep in touch.
David：现在回到威斯康星大学的朱迪。她正在与 Slack 医生和那里的医疗部门合作，进行各种应用程序项目。然后 Slack 医生搬到了哈佛，在那里他当然遇到了尼尔，并开始与 Meditech 合作。但他和朱迪一直保持联系。

Judy’s part of this community of programmers and computer scientists building applications for healthcare systems. And like we said earlier, what the people at Wisconsin really want, is the same thing that the people at Harvard and MGH really want, is this integrated system where they can get longitudinal patient records across the continuum of care, and that they can use to bill the payers.
Judy 是这个由程序员和计算机科学家组成的社区中的一员，他们为医疗系统开发应用程序。就像我们之前所说的，威斯康星州的人们真正想要的，与哈佛和 MGH 的人们真正想要的是一样的，即一个集成系统，他们可以在整个医疗照护 continuum 中获取 longitudinal 患者记录，并使用这些记录来向支付方收费。

Ben: The Holy Grail.  Ben: 圣杯。

David: The Holy Grail. Through this connection, Judy learns about MUMPS. She goes and learns MUMPS the programming language, starts working on this problem, and legend has it that one day in the mid-1970s, she’s sitting in her living room and has an epiphany about how she is going to build a great system, a single database that can do all of this.
大卫：圣杯。通过这个连接，朱迪了解到 MUMPS。她去学习 MUMPS 这种编程语言，并开始着手解决这个问题。传说中，在 20 世纪 70 年代中期的一天，她在客厅里突然有了一个灵感，关于她将如何构建一个伟大的系统，一个能够完成所有这些工作的单一数据库。

Her quote on this is, “The sun was shining, I was dis-attentive, I was just sitting there, and suddenly it all came to me. Here’s how you build it. The integrated system. I remember running to the kitchen, grabbing a pad of paper, and just writing code, code, code, code.” That code became Chronicles. It’s a chronicle of a patient’s care journey. That code in that database is still the core of Epic to this very day.
她对此的评价是：“阳光明媚，我注意力不集中，只是坐在那里，突然间一切都豁然开朗。这就是你如何构建它的。集成系统。我记得跑去厨房，拿了一张纸，就开始写代码，代码，代码，代码。”这段代码成为了 Chronicles。数据库中的那段代码至今仍是 Epic 的核心。

Ben: Is it actually the same code?
Ben: 真的是相同的代码吗？

David: No. She’ll claim none of my code that I wrote is still in production, et cetera. I’m sure that is true. But it is true that Epic’s core database, the core single database—this is Epic’s big differentiation—there’s only one database that every application pulls from.
大卫：她不会声称我写的任何代码仍在生产中，等等。我相信这是真的。但确实存在一个核心数据库，即 Epic 的核心单一数据库——这是 Epic 的一大差异化因素，所有应用程序都从中提取数据。

Ben: Directly talks to.  Ben: 直接交谈。

David: It directly talks to, whether it’s the clinical side for EMRs, whether it’s the billing side with the resolute module that Epic has, whether it’s Cosmos, whether it’s Stork for OB gyn or Beans for Kidney or whatever application that Epic makes of their hundreds, it all pulls from one single database in Chronicles, and that’s what Judy writes here in the 1970s.
大卫：它直接与之对话，无论是临床方面的电子病历，无论是通过 Epic 的决算模块进行的收费，无论是 Cosmos，还是用于妇产科的 Stork 或用于肾病的 Beans，或是 Epic 制作的任何其他应用程序，它们都从 Chronicles 中的一个单一数据库中提取数据，而 Judy 在 20 世纪 70 年代在这里写道。

Ben: Okay, so it’s just a database? Where does it go from, she writes a bunch of code when she has this insight that there should be a database with the patient model at the center?
本：好吧，那只是一个数据库？当她有了这样的见解，认为应该有一个以患者模型为中心的数据库时，她写了很多代码吗？

David: Well, that’s a good question because it is just a database. The idea of applications and certainly graphical applications on top of it doesn’t make sense because we’re still in the mainframe world here. What the product is, is this database, then different departments in the Wisconsin Medical Center can write their own screens, like queries on top of the database that can sit on their terminals, and that they can read data out of the database directly into their patient rooms or departments, wherever they’re sitting.
David: 这确实是一个好问题，因为这只是一个数据库。在上面开发应用程序，尤其是图形应用程序的想法并不合适，因为我们仍然处于主机系统的世界。产品的本质就是一个数据库，然后威斯康星医疗中心的不同部门可以编写自己的界面，就像在数据库上进行查询，这些查询可以放在他们的终端上，他们可以直接从数据库中读取数据到患者的病房或部门，无论他们坐在哪里。

Ben: So these are terminals. These are 80-character-wide text-only terminals.
本：这些都是终端。这些是仅显示 80 个字符宽的文本终端。

David: Yes. Green screens, Unix terminals.
大卫：是的。绿色屏幕，Unix 终端。

Ben: Okay, so you run Judy’s database, you run Chronicles somewhere in your hospital building on a big mainframe, and then there are these text only terminals that can query it.
本：好的，所以你运行 Judy 的数据库，你在医院大楼里的某个地方运行 Chronicles，然后还有一些只能查询的纯文本终端。

David: That’s the product.
这就是产品。

Ben: Sweet. Long way to go.
本：很好。还有很长的路要走。

David: Just like the projects in Boston at MGH where the intention was to make the systems for use there at MGH, Judy at first is just making Chronicles for the Wisconsin Medical System. She’s just a programmer employee of the medical center.
David: 正如波士顿 MGH 项目的初衷是为 MGH 制作系统一样，朱迪最初只是为威斯康星医疗系统制作 Chronicles。她只是医疗中心的一名程序员员工。

But the doctors at UW are going to academic conferences all around the country, and they start telling other doctors at other academic institutions about this great system called Chronicles that they have, that this programmer that they employ, Judy Faulkner has written, and demand for it starts to spread virally. Wisconsin gets calls and then Judy gets calls from all these other health systems around the country that are like, oh hey, can you write this for me too?
但威斯康星大学的医生们在全国各地的学术会议上发表演讲，他们开始向其他学术机构的医生们介绍他们拥有的这个名为 Chronicles 的优秀系统，这个系统是由他们雇用的程序员朱迪·福克纳编写的，对这个系统的市场需求开始像病毒一样传播开来。威斯康星州收到了电话，然后朱迪从全国各地的其他医疗系统那里接到电话，他们说：“嘿，你们能为我写一个类似的系统吗？”

Ben: Doesn’t she get asked to start a company several times? And she’s like, no, I just made it this one instance. We don’t need to build a whole company around this thing.
本：她不是被问过好几次要不要创办公司吗？她回答说，不，我只是这一次侥幸成功了。我们不需要为这个东西建立整个公司。

David: Exactly, and this happens again and again and again. Legend is finally, she just breaks down, is like, fine. I’ll start a company. I’ll be part-time on it. We’ll get some other people who are working with me, who will be part-time. This will be a small little thing. Thus finally in 1979, the company is born, Human Services Computing.
大卫：正是这样，而且这种情况一次又一次地发生。最终，她崩溃了，说好吧，我要创办一家公司，我会兼职做这件事。我们会找一些和我一起工作的其他人，他们也会兼职。这将是一件小事。因此，最终在 1979 年，这家公司成立了，名为 Human Services Computing。

Ben: Amazingly generic.  Ben: 真是太通用了。

David: The future Epic Systems. But before we tell the story of how Human Services Computing became Epic…
大卫：未来的 Epic 系统。但在我们讲述 Human Services Computing 如何成为 Epic 的故事之前……

Ben: This is a great time to thank our presenting partner, J.P. Morgan Payments, and in particular to dive into how essential modern payments infrastructure has become to building your business today, whether you are a large multinational business or a startup in your early days of processing payments.
Ben: 这是一个很好的机会感谢我们的プレゼンテーション合作伙伴 J.P. Morgan Payments，并特别探讨现代支付基础设施对今天构建您的业务有多么重要，无论您是大型跨国企业还是初创企业在早期处理支付的阶段。

David: If you think about it, there are whole companies and industries that couldn’t exist a decade ago without the payment tools we have today. It’s absolutely essential to create businesses with modern product experiences like ride sharing, the creator economy, or B2B use cases like SaaS marketplaces or managing supplier relationships. For those types of companies, payments is their business.
David：如果你想想看，很多公司和行业在没有我们今天这些支付工具的情况下，十年前是无法存在的。现代产品体验，比如共享出行、创作者经济，或者 B2B 场景下的 SaaS 市场或供应商关系管理，对于这些类型的公司来说是至关重要的。对于这些公司而言，支付就是他们的业务。

Thankfully, J.P. Morgan has built the stack to let them focus on their differentiation instead of reinventing the wheel. J.P. Morgan payments has been pioneering in this industry for decades. They move $10 trillion a day. You can literally never outgrow their capabilities.
感谢 J.P.摩根构建了这一栈，让他们可以专注于自己的差异化，而不是重新发明轮子。J.P.摩根支付业务在这一行业已经领先数十年。他们每天处理的金额高达 10 万亿美元。你真的永远无法超越他们的能力。

Ben: While we are examining the healthcare landscape today, let’s look at the industry through the lens of payments. There’s a lot of innovation promise coming with telehealth, AI, preventative treatment, and new clinical trial processes. Seamless and secure payments are critical to improving patient experiences in unlocking innovation for businesses and providers.
本：在我们审视当今的医疗保健格局时，让我们通过支付的角度来观察这个行业。随着远程医疗、人工智能、预防性治疗以及新的临床试验流程的出现，有很多创新的潜力。无缝且安全的支付对于改善患者体验、为企业和提供者解锁创新至关重要。

When you zoom out, healthcare is an incredibly complicated ecosystem of payments, healthcare providers, insurance network specialists, health monitoring services and more. It creates a complex and friction-filled payment experience—who’s paying who, when, and under what terms. Then you layer data privacy requirements on top. It’s wild.
当你退后一步看，医疗保健是一个极其复杂的生态系统，包括支付、医疗服务提供者、保险网络专家、健康监测服务等等。这创造了一个复杂且充满摩擦的支付体验——谁在什么时候以什么条件支付。然后你还得加上数据隐私要求。真是疯狂。

David: If you’re a company or a provider trying to innovate in this space, you know getting the payments piece right is paramount, which is why J.P. Morgan’s array of products, including their healthcare payment solutions and InstaMed offering, provides a patented cloud-based technology to securely transform healthcare payments by driving electronic transactions, processing payments, and moving healthcare data seamlessly.
David：如果你是一家公司或医疗服务提供者试图在这个领域创新，你就会知道把支付部分做好至关重要，这也是为什么摩根大通的各种产品，包括他们的医疗支付解决方案和 InstaMed 提供的服务，能够提供一种专利的基于云的技术，以安全地转型医疗支付，推动电子交易，处理支付，并无缝移动医疗数据。

Ben: If you’re in the industry, you likely know that J.P. Morgan is finally attuned to all these innovations on the frontier hosting the premier healthcare industry event every January. If you learned anything at this year’s event that’s relevant to this episode, come share it with us in the Slack. Listeners can check out jpmorgan.com/acquired to learn about how J.P. Morgan’s end-to-end payment solutions can accelerate your business and discover more innovation happening across all industries.
Ben：如果你在行业里，你应该知道 J.P. Morgan 终于开始关注这些前沿的创新了。每年一月，J.P. Morgan 都会举办首屈一指的医疗行业盛会。如果你在今年的活动中了解到任何与本集相关的内容，欢迎在 Slack 里与我们分享。听众可以访问 jpmorgan.com/acquired，了解 J.P. Morgan 的端到端支付解决方案如何加速你的业务，并发现其他各行业的创新。

All right, so David, Judy leaves her job, she starts, what is it? Human Computer…
好的，所以大卫，朱迪离职了，她开始做的是什么？人工计算机……

David: Human Services Computing.
David: 人类服务计算。

Ben: Human Services Computing.
Ben: 人类服务计算。

David: Really rolls off the tongue.
大卫：真好听读出来。

Ben: She’s not planning up to this point to be the founder of a company, and yet for the next 47 years of her life she would be. How does that go?
本：她原本并没有打算成为一个公司的创始人，然而在接下来的 47 年里，她就是了。这怎么可能？

David: Well, before she does anything, she needs to raise some money for not the least of which to buy a computer to do this work on.
大卫：在她做任何事情之前，她需要筹集一些资金，其中最重要的是买一台计算机来做这项工作。

Ben: Which, wasn’t it like $70,000 to buy a computer?
本：对，买一台计算机不是要花 7 万美元吗？

David: Yes. A computer being a Data General Eclipse 16-bit minicomputer, which is the size of a washer and dryer system that sits in the basement.
大卫：是的，这台计算机是一台 Data General Eclipse 16 位小型计算机，大小相当于一个烘干机和洗衣机的系统，放在地下室里。

Ben: That’s right because we’re in this awkward era between mainframes and microcomputers. The microprocessor hasn’t been invented yet. We have these “minicomputers” that are still washing machine sized.
本：正是因为在大型主机和微机之间这个尴尬的时代，微处理器尚未被发明。我们仍然有这些“小型计算机”，它们的大小还像洗衣机一样。

David: We’re right before the PC era here.
大卫：我们正处于个人电脑时代之前。

Ben: It’s so interesting how sometimes you have the technology wave that eclipses all prior, but sometimes you have these half steps along the way that turn out not to eclipse everything.
本：有时候技术浪潮会超越之前的一切，但有时候也会有这些半步进展，结果并没有超越一切。

David: Minicomputers were like the netbooks of their time. We talked about this a lot on our Microsoft episodes, but the critical thing about minicomputers, and especially for Judy here and fledgling Epic, was a consumer wouldn’t buy these things, but small businesses could, and small departments of big companies could.
微型计算机就像是那个时代的上网本。我们在讨论微软的时候也提到过这一点，但关于微型计算机，尤其是对朱迪和初创的 Epic 来说，关键在于消费者不会购买这些设备，但小型企业可以购买，大型公司的小部门也可以购买。

An IBM mainframe system was going to cost you a lot of money. A Data General or DEC minicomputer is going to cost you about $70,000, and Judy needs to buy one. She also needs to fund the company. She goes to the bank and she gets a bank loan for $70,000 to finance and buy the data General Eclipse minicomputer.
IBM 主机系统会花费你很多钱。Data General 或 DEC 的小型计算机大约要花费 7 万美元，Judy 需要买一台。她还需要为公司筹集资金。她去银行申请了一笔 7 万美元的贷款来融资并购买 Data General Eclipse 小型计算机。

She rounds up a bunch of friends, family, and other people, whether physicians or other programmers in the University of Wisconsin system who are working with her on these projects, to invest money in the new company. Together, they all put in about $70,000. They value the company at $70,000, so pre-money valuation of $70,000.
她召集了一群朋友、家人以及其他人员，无论是医生还是威斯康星大学系统中的其他程序员，这些人正在与她一起参与这些项目，共同投资新公司。他们一共投入了大约 7 万美元，公司估值为 7 万美元，因此是 7 万美元的预估值。

Ben: Another $70,000 of new on top.
Ben: 又增加了 70,000 美元。

David: Post money of $140,000.
David: 投资金额为 140,000 美元。

Ben: Taking 50% dilution from your $70,000 fundraise, and then you also have this $70,000 loan.
Ben: 从你 70,000 美元的融资中稀释 50%，然后你还有一笔 70,000 美元的贷款。

David: And those were the only primary investors ever in Epic Systems. There are some really fun stories about what happened to those shares that the other original investors bought over time. The company has bought a lot of them back, but not all of them.
大卫：Epic Systems 只有这些最初的 primary 投资者。关于其他原始投资者购买的股份后来发生了什么有趣的故事很多。公司回购了很多股份，但并不是全部。

Ben: There are still some floating out there.
本：还有一些在外漂着。

David: There are some floating out around there. We can’t share all the stories that we heard in the research, but one fun thing is that at one point in time, I think this was probably the 2000s maybe, a pretty good chunk of those shares made their way to Sequoia Capital. Sequoia did not put that one on their website.
David: 那里有一些流传出来。我们不能分享所有在研究中听到的故事，但有一件有趣的事情是，我想这可能是在 2000 年代左右，相当一部分这些股份流向了 Sequoia Capital。Sequoia 并没有将这个信息放在他们的网站上。

Ben: Almost the only way in which Epic intersected with Silicon Valley in the entire company’s history, but this is a crazy point. They do $5.7 billion in revenue today. They dominate an industry, at least here in the United States, and in total they raised $70,000 of equity capital and $70,000 of bank debt.
Ben: 整个公司历史上几乎唯一与硅谷有所交集的方式，但这真是一个疯狂的点。他们今天的营收达到 57 亿美元。他们在至少美国的行业内占据主导地位，而他们总共筹集了 7 万美元的股权资本和 7 万美元的银行债务。

David: And that’s it.
大卫：这就完了。

Ben: This is IKEA all over again.
本：这和宜家又是一个样。

David: Totally, and I think a huge part of what enabled this building software is not necessarily a capital-light activity. It is really hard, especially in those days to build great software. I think how Microsoft never really raised primary capital either. It’s because Judy got generational talent as a programmer.
David: 完全同意，我认为这种构建软件的能力并非一定是轻资产活动。尤其是在那些日子里，要构建伟大的软件是非常困难的。我认为微软也从未真正筹集过主要资本，这是因为朱迪获得了代际人才作为程序员。

Ben: I hadn’t made that linkage. That’s interesting.
本：我没有建立起这种联系。这挺有趣的。

David: They had a cornered resource as a startup. Microsoft did in Bill Gates and Paul Allen, too, but Epic totally did too in Judy. She could write really, really great software.
David：他们作为初创公司有一个被围困的资源。微软也有比尔·盖茨和保罗·艾伦，但伊克希普也完全有朱迪。她能写出非常出色的软件。

Ben: They didn’t need to go hire an army of programmers.
Ben: 他们不需要雇佣一支程序员大军。

David: And the company stayed very, very small for a very long time.
大卫：很长一段时间里，公司都非常小。

Ben: Because as legend has it, it’s three halftime people in the basement of a building that started the company, and I think they got pretty far on just that.
本：因为据传说，这家公司是三个人在一间大楼的地窖里开始的，而且他们仅凭这一点就取得了相当大的成就。

David: I think so, and for years they didn’t hire that many more people. That would obviously change over time.
大卫：我想是这样的，而且多年来他们并没有雇用太多新员工。这种情况显然会随着时间改变。

Okay, I am 90% sure I’m going to stump you on this one. You mentioned the basement of the building. They get their first office space. Judy gets the company’s first office space in the basement of an apartment building at 2020 University Avenue in Madison, Wisconsin. Do you know what other great American company from Madison, Wisconsin also started in that same office space, and I believe overlapped. I think they were both in this same shared office space concurrently.
好的，我有 90%的把握你会被这个问题难倒。你提到了大楼的地下室。他们获得了第一个办公空间。朱迪在威斯康星州麦迪逊市 2020 大学大道的一栋公寓楼的地下室获得了公司的第一个办公空间。你知道吗，同样来自威斯康星州麦迪逊市的另一家伟大的美国公司也曾在同一个办公空间开始，并且我认为他们同时共用过这个办公空间。

Ben: David, there’s only so much material out there on this company. We were both going to find this. Listeners, this is the American Girl doll company.
Ben: David，关于这家公司的资料并不多。我们俩本来都会找到的。听众们，这是美国女孩娃娃公司的资料。

David: I really thought I had you on this. Ben and I don’t do our research calls together. We do most of them separately, but we were on one together. The person we were talking to was about to say this and I was like, no, don’t say it. I want to stump in on the episode.
大卫：我真以为这次能难倒你了。本和我通常不会一起做研究电话，我们大多数时候是分开做的，但这次我们是一起做的。我们正在交谈的人就要说那句话了，我当时就说，别说了，我想插一句。

Ben: I did see it somewhere else, though. The crazy thing is, I think when American Girl moved out, Epic bought some of their furniture.
本：虽然我在别的地方见过，但很疯狂的是，我想当 American Girl 搬走后，Epic 买了一些他们的家具。

David: I think that’s right. Listeners, what we’re talking about is the American Girl doll company founded by Pleasant Rowland in Madison, Wisconsin.
大卫：我想这是对的。听众们，我们谈论的是由 Pleasant Rowland 在威斯康星州麦迪逊创立的 American Girl 娃娃公司。

Ben: My sister had (I think) a few of these growing up.
本：我姐姐（我想）小时候有一些这样的东西。

David: Oh man. Jenny had so many of these. A lot of them have migrated now to our house and our girls have them. Already, my three-year-old runs around our house with the American Girl doll magazine, and she tells me on a weekly basis, these are the ones I want for my birthday, and she’s pointing at a $250 doll. Incredible company. It actually ends up getting acquired by Mattel in the late-90s. It was a big part of Mattel for a long time.
大卫：天哪。詹妮有很多这样的玩具。现在很多都移到了我们家里，我们的孩子们也有。已经到了，我三岁的女儿在家里到处跑着拿着美国女孩娃娃杂志，她每周都会告诉我她想要的生日礼物是什么，而且她指着的是一只标价 250 美元的娃娃。真是不可思议的公司。实际上，它最终在 20 世纪 90 年代末被美泰公司收购了。它很长时间都是美泰公司的重要组成部分。

Oh, I’m so bummed I didn’t stump you on this one. Okay, back to the Epic story. Judy’s got the financing, she’s got the computer, but she still doesn’t know anything about building and running a company. She’s a software developer. Warner Slack says, okay, come on out to Boston. I’m going to set up a couple of days for you to spend time with Neil and Meditech. I’m going to ask him to help you out starting this company.
Oh, 我真失望没有在这次难倒你。好吧，回到 Epic 的故事。朱迪已经搞到了资金，也有了计算机，但她仍然不懂如何建立和运营一家公司。她是一名软件开发者。华纳· slack 说，好吧，来波士顿吧。我要安排你和尼尔以及 Meditech 待上几天。我要请他来帮助你开始这家公司的运营。

Ben: I got to say this is a pivotal moment, and not just for everything she learns from Meditech, which I know you’re going to get into all these cool things that she brought over. But instead of, I’m going to introduce you to a business person, he says, I’m going to teach you as a programmer everything you need to know about running a business.
Ben: 我得说这是一个关键的时刻，不仅仅是因为她从 Meditech 学到的一切，我知道你会了解到她带来的所有酷炫的东西。但他要说的是，他要教你作为一个程序员需要知道的所有关于运营一家公司的知识。

It’s not true, but it rounds to true to say Epic basically never did hire any business people. It is essentially a big gigantic company of programmers, logicians, implementation people who could be programmers who think like programmers. That is the DNA of the company to this day. And it could have gone in a super different direction of you need to go figure out a sales and marketing strategy and a business plan. That is just not what happened.
它不完全正确，但可以说基本上 Epic 从未雇用过任何商业人员。这基本上是一家由程序员、逻辑学家和实施人员组成的大型公司，这些人可能就是像程序员一样思考的程序员。这就是公司至今的 DNA。它本可以走向完全不同的方向，即你需要制定销售和营销策略以及商业计划。但这一切都没有发生。

David: This is a history turns on a knifepoint–moment for Epic and Judy because the likelihood that she would get introduced to a business mentor, who is also a software developer and not a business school graduate business guy, we’re talking about the 1970s here. The business playbook is you bring the grown ups in. Bring in the suits. Bring in the business school graduates. Fire the founders.
David：这是一个刀锋上的历史转折点——对于 Epic 和 Judy 来说，因为很有可能她会遇到一位既是软件开发者又不是商学院毕业生的商业导师。我们说的是 1970 年代的事情。当时的商业教科书是：请来成年人，穿上西装，聘请商学院毕业生。解雇创始人。

Ben: But that only happens if you raise capital.
Ben: 但这只会在你筹集资金时发生。

David: Exactly. You wonder why Judy was so averse to venture capital. Everybody else she knew who was taking it in that era was getting fired.
大卫：正是这样。你可能会好奇，朱迪为什么如此反对风险投资。在那个时代，她认识的其他人接受了风险投资后都被解雇了。

Ben: Swapped in for a business guy.
Ben: 顶替了一个商务人员的职位。

David: Totally. Neil came out of MIT. He’s a programmer. He was on the original MUMPS team. So Judy goes out, spends three days with Neil and gets a total crash course in setting up and running a company.
大卫：完全正确。尼尔从麻省理工学院毕业。他是一名程序员。他是 MUMPS 团队的原始成员。所以朱迪出去，花了三天时间与尼尔在一起，得到了如何设立和运营一家公司的全面课程。

Ben, like you said, Neil ran Meditech like a software developer, so all the processes were extremely standardized. He had hardened APIs for running the company. He had manuals and documentation for everything, and he shared the manuals with Judy. This is how you set up a HR system. This is how you do benefits payroll,
Ben，就像你说的，Neil 把 Meditech 管理得像一个软件开发项目一样，所以所有的流程都非常标准化。他为公司运行制定了坚固的 API，有手册和文档涵盖一切，并且他把手册分享给了 Judy。这是如何设置人力资源系统的。这是如何处理福利和薪资的。

Ben: How you do college hiring. How you promote internally.
本：你们是如何进行大学招聘的。你们是如何内部晋升的。

David: Meditech recruited from the universities there in Boston. They didn’t hire experienced programmers. They were hiring fresh college graduates. Totally natural that Judy’s going to do the same thing at Epic out of first the University of Wisconsin and then other schools. That was the playbook, and that DNA runs right through to this very day at Epic.
大卫：Meditech 在波士顿那里从大学招聘。他们没有雇佣有经验的程序员，而是招聘应届毕业生。Judy 在 Epic 也会采取同样的做法，首先是威斯康星大学，然后是其他学校。这就是他们的模式，这种基因一直贯穿到今天在 Epic 的方方面面。

Ben: It’s mostly people from non-medical majors. They’re hiring from Midwestern schools, from people with technical majors just operating under the assumption, eh, you can learn this healthcare thing.
本：这些人 mostly 来自非医疗专业。他们从中西部学校招聘，从拥有技术专业背景的人中招聘，只是假设，你们可以学习医疗相关知识。

David: It’s the same thing as Microsoft or Google or Meta or what have you. They are going to universities, all departments, and recruiting kids on campus, recruiting at colleges.
大卫：这和微软、谷歌或 Meta 一样，他们去大学，所有部门，校园招聘，也在学院招聘。

Ben: And she was doing this at a time when it wasn’t the norm. I got to keep drilling in how different the world was then in a bunch of different ways. But one of them was you didn’t have these college career fairs where you would just assume you could get this amazing high agency job right out of college. Microsoft was really on the frontier of hiring smart college grads and empowering them and letting them run free. Epic was doing the same thing, and this was not industry standard.
Ben：而且她是在这种情况下做的，这并不是常态。我有机会强调当时的世界在许多方面都大不相同。其中一个方面是，你不会参加那些你认为可以轻松获得高自主性工作的大学职业博览会。微软在招聘聪明的大学毕业生并赋予他们权力、让他们自由发挥方面处于前沿。Epic 也在做同样的事情，而这并不是行业标准。

David: And Microsoft wasn’t even really doing it at this point in time. They had only just moved to Washington. They’d only just left Albuquerque. This is the timeframe we’re talking about.
David: 而此时微软还没有真正涉足这一领域。他们刚刚搬到华盛顿，之前还在阿尔伯克基。我们谈论的就是这个时间段。

Ben: What year are we in?
本：我们现在是哪一年？

David: We’re in 1979.
大卫：我们现在是 1979 年。

Ben: Microsoft really isn’t starting to wrap hiring yet.
Ben: Microsoft 真的还没有开始招聘。

David: No, and to that point, there is no DOS yet. There is no real PC industry. Microsoft’s main product is the BASIC interpreter. For Judy and the fledgling Human Services Computing here, yes, they have demand from other large academic hospitals out there and medical systems that have mainframes set up, that have university computing infrastructure that they can leverage and use. But your average hospital or medical clinic or outpatient clinic out there in America doesn't have a minicomputer. They don’t have a mainframe. The market isn’t really there for this stuff yet in a big way, except at these university medical systems.
David: 不，到目前为止还没有 DOS。真正的个人电脑产业还没有兴起。微软的主要产品是 BASIC 解释器。对于朱迪和这里刚刚起步的卫生服务计算来说，确实有其他大型学术医院和其他医疗系统的需求，这些系统有大型机，可以利用和使用大学的计算基础设施。但美国普通的医院、医疗诊所或门诊诊所还没有小型计算机，也没有大型机。这个市场还没有真正为这些产品做好准备，除了在这些大学医疗系统中。

Ben: And part of what she is doing is going after a different segment than Meditech was doing is a little bit out of deference to Neil and his company. They’re going after the small hospital market. She’s going to take a more upmarket enterprise-y approach, and go after the most complex institutions, these academic training hospitals, later on the IDNs or the integrated delivery networks, which are huge hospital systems, or children’s hospitals. Again, the most complex, upmarket, enterprise-y, has the most possible needs for the most complex software, that is where she’s about to point the company.
Ben: 而她正在做的事情之一是，瞄准与 Meditech 不同的市场细分，这在一定程度上是对尼尔和他的公司的尊重。她们将瞄准小型医院市场。她将采取一种更高端的企业化策略，后来再转向学术培训医院，或者整合医疗服务网络（IDNs），这些是巨大的医院系统，或者儿童医院。再次强调，最复杂、最高端、企业化程度最高的地方，拥有对最复杂软件最多的潜在需求，她将把公司的发展方向瞄准这些地方。

David: Which she has to for the Unix-based product that she’s making, because those are the only institutions that have Unix infrastructure.
David: 她必须为她正在开发的基于 Unix 的产品这样做，因为只有这些机构拥有 Unix 基础设施。

Ben: That can afford these big computers.
本：这可以负担得起这些大型计算机。

David: So 1979, they started out with four initial customers. Four years later in 1983 is when they renamed the company to Epic Systems. Ben, why did they rename the company?
1979 年，他们最初有四个客户。四年后的 1983 年，他们将公司更名为 Epic Systems。本，他们为什么要更改公司名称？

Ben: Well, aside from the first name just being an awful name, you can start to see Judy’s quirkiness come through. I think you saw it originally with Chronicles, her abstract creative thought, the notion of an epic, the Greek epic is this big story, this big longitudinal, historic event. And I think the way that she’s thinking about a patient record is that the life of the patient is an epic. Does that jive with your understanding?
本：除了名字本身就很糟糕之外，你可以开始看到朱迪的古怪之处。我认为你最初在《编年史》中看到了这一点，她的抽象创造性思维，史诗的概念，希腊史诗是一段宏大的故事，一段长期的历史事件。我想她认为病历记录是患者一生的史诗。这与你的理解一致吗？

David: Yeah. It definitely was not a declaration of aspirations as a company because this was still a very, very small business. They started with four initial customers in 1983 when they changed the name. They only have nine customers. In fact, by the end of the company’s first decade of existence, at the end of 1988, they only have 24 customers. It’s only doing $1.5 million in revenue, and they’ve got a handful of employees. That’s the crazy thing. Unlike Microsoft, this was a small business from the get-go.
大卫：是的。这绝对不是一家公司的宣言，因为当时这还是一家非常非常小的公司。他们是在 1983 年改名时开始的，最初只有四个客户。实际上，到 1988 年底，也就是公司成立的第一十年结束时，他们也只有 24 个客户。他们的收入只有 150 万美元，而且只有几名员工。这才是最疯狂的地方。与微软不同，这从一开始就是一家小公司。

Ben: It took a decade to get to $1.5 million in revenue. That’s a slow grubbing startup.
Ben: 获得 150 万美元的收入花了十年时间。这是一家发展缓慢的初创公司。

David: A great software business for a local entrepreneur in Madison, Wisconsin, I think is how you would describe that. For the first 10 years of the company, yes it’s growing, but it’s not exactly setting the world on fire. Part of the reason is the computing infrastructure wasn’t their customers, like we talked about.
大卫：这是一家来自威斯康星州麦迪逊的本地企业家的伟大软件公司。在公司的前十年，确实是在增长，但并不是在彻底改变世界。其中一部分原因是因为计算基础设施并不是他们的客户，就像我们之前提到的。

The other big reason why they weren’t getting crazy customer adoption is they actually were only doing the clinical medical record stuff at this point in time. They weren’t doing the really important stuff of the billing system until 1987. For the first, what is that, call it eight years of the company, they weren’t addressing the actual critical problem in the hospitals, which is to help us bill for this stuff.
他们没有获得疯狂的客户采用的另一个重要原因是在这个时间点上，他们实际上只在做临床医疗记录的工作。直到 1987 年，他们才开始做真正重要的收费系统工作。在公司的前八九年时间里，他们并没有解决医院实际的关键问题，即帮助我们为这些服务收费。

Ben: If you can help them make more money, they’re going to be a lot more excited to buy your software, and pay a lot more for your software.
Ben: 如果你能帮助他们赚更多钱，他们就会更愿意购买你的软件，并为你软件支付更高的价格。

David: Totally, In 1987, they launched a billing module called Resolute, again on top of the Chronicles’ single core database, which still today is the company’s revenue cycle application for all their hospitals. I know we’ve made this point a few times, but I really want to underline, it is still just an application built on top of the Chronicles database. Fast forward to today, I think that is actually the single biggest reason why Epic wins over their competitors.
David: 完全正确。1987 年，他们推出了一款名为 Resolute 的计费模块，该模块基于 Chronicles 的单核数据库，至今仍是该公司所有医院的收入周期应用程序。我知道我们之前已经提到过这一点，但我真的想强调，它仍然只是一个基于 Chronicles 数据库的应用程序。快进到今天，我认为这实际上是 Epic 战胜竞争对手的最关键原因。

Ben: I would argue there are two big reasons Epic wins today. One is reliability. But the reliability also comes from the fact that it’s all built on one database. You’re not gluing multiple systems together. All their competitors along the way, or almost all of them other than Meditech, became 30 other companies glued together through M&A, take public, take private crazy transactions. Epic’s just been Epic the whole time.
Ben：我认为 Epic 今天获胜有两个主要原因。一个是可靠性。但这种可靠性还来自于它全部建立在一个数据库之上。你不需要将多个系统拼接在一起。一路上的所有竞争对手，或者几乎所有的竞争对手，除了 Meditech 之外，都变成了通过并购、上市、私有化等疯狂交易粘合在一起的 30 家公司。而 Epic 从始至终都是 Epic。

You get this system, that when you buy it and they say it’s going to take X dollars and X time to implement, it does. Then you go live and it works, which sounds crazy, but it does the thing that they say it’s going to do on time and on budget, or as good as anyone does in this industry.
你得到这个系统，当你购买它并被告知实施将花费 X 美元和 X 时间时，它确实会这样做。然后你上线，它正常工作，这听起来很疯狂，但它确实按预定的时间和预算做到了，或者至少和这个行业里做得最好的人一样好。

Then the second reason in addition to reliability, David, as you’re alluding to, is the fact that the clinical side and the billing side are completely stitched together in one code base working off of one database. It is perfect harmony. You don’t have information dropped when one system is talking to another. If your goal is to adopt a system that keeps track of everything in your hospital and make sure that you can make money from it for your organization, this is the ideal architecture for such a product.
然后除了可靠性之外，大卫，正如你提到的，临床侧和收费侧是完全集成在一个代码库中，并共享一个数据库。这达到了完美的和谐。当一个系统与另一个系统交流时，不会丢失信息。如果你的目标是采用一个能够全面跟踪医院中所有事务，并确保为你的组织带来收入的系统，那么这种产品的架构正是你所需要的。

David: It’s funny. I’m laughing as you were saying earlier of it does what it’s supposed to do. As with the [...] I assume you’re referring to the actual clinician doctor–facing EMR side of it. If you’re looking for a system as a hospital that ties what happens in your medical practice to your billing and your revenue events, there is no if.
大卫：真有趣。你刚才说它做到了它应该做的事情，我都在笑。就像你提到的那样，我假设你指的是实际面对医生的电子病历系统。如果你是一家医院，想要一个系统将你的医疗实践中的事情与你的收费和收入事件联系起来，那毫无疑问。

Ben: That’s all you’re trying to do as a hospital.
本：你们医院想做的就是这些。

David: This is what you are looking for. That is the product. And Ben, like you said, all the competitors out there, except arguably Meditech, in many cases, the billing system is a separate and often separately-acquired product from the medical record.
大卫：这就是你要找的。那就是产品。本，就像你说的，除了 Meditech 之外，许多情况下，收费系统是一个单独的产品，并且通常是单独购买的，与医疗记录分开的。

Not only is it just like, oh, maybe not ideal if some of the information doesn’t pass quickly or efficiently or accurately between those two systems, it’s incredibly not ideal. It’s like you’re not getting paid for the work you’re doing. Or even worse, maybe you’re submitting documentation that is wrong, which is a federal crime.
不仅如果有些信息不能快速、高效、准确地在这两个系统之间传递，那简直不是理想的情况，它简直是糟糕透了。这就像你没有得到你所做工作的报酬。更糟糕的是，你提交的文件可能是错误的，这可是联邦犯罪。

Ben: Or even if it’s bad in the other direction, then it’s not just that your billing system is not making it into clinical, you’re potentially causing patient harm and costing lives. Any data flowing in either direction that’s bad is really, really bad in this particular use case.
本：或者即使是从另一个方向来看，如果情况很糟糕，那不仅仅是你的收费系统没有进入临床，你可能还在造成患者伤害并夺走生命。在这种特定情况下，任何从任一方向流动的糟糕数据都是非常糟糕的。

There’s a great Substack called Health API Guy, which I’m going to reference a few times because it’s just some of the best writing on Epic you’ll find. He put it perfectly.
有一个很棒的 Substack 叫做 Health API Guy，我将要引用几次，因为它是你能找到的关于 Epic 最精彩的写作之一。他表达得完美无瑕。

“Epic becomes the natural choice for enterprise decision makers, precisely because of its integrated system architecture. Rather than managing multiple vendors and systems, buyers get a comprehensive platform with a single database, unified workflows, and built in operability through Care Everywhere,” which we’ll talk about later. Care Everywhere is the magical button that makes it so that your hospital records at one hospital are easily integrated and viewed in any other hospital that is (of course) also an Epic customer.
“Epic 成为企业决策者的自然选择，恰恰是因为其集成系统架构。买家不需要管理多个供应商和系统，而是获得一个全面的平台，拥有单一数据库、统一的工作流程，并通过 Care Everywhere 实现内置的操作性，”我们稍后会谈到 Care Everywhere 这个神奇的按钮，它使得你在一家医院的医疗记录可以在任何其他也是 Epic 客户的医院中轻松集成和查看。

David: After they launch Resolute—now we’re in the late-80s into the early-90s—we’re finally entering the PC era. It’s now possible for hospitals and health practices to adopt computers for a few thousand dollars instead of a few tens of thousands of dollars. The market really starts to take off for Epic. On the back of that, in 1992, they launch EpicCare, which I believe is the first graphical user interface, like Windows-based EMR application in the entire industry.
David：在他们推出 Resolute——大约是 80 年代末到 90 年代初——我们终于进入了个人电脑时代。现在，医院和医疗实践可以以几千美元而不是几万美元的价格采用计算机。Epic 的市场真正开始起飞。在这一背景下，1992 年，Epic 推出了 EpicCare，据我所知，这是整个行业中第一个基于图形用户界面的 Windows 基础的电子医疗记录应用程序。

Ben: Certainly. Epic definitely says that that is true.
Ben: 当然。Epic 确实这么说的。

David: So what does that mean? Go back to what Chronicles was originally. It was terminal access directly into a Unix-based database on a mainframe or on a minicomputer. This is not something that your average doctor or nurse or medical assistant is going to use.
大卫：那是什么意思？回到 Chronicles 最初的样子。它直接访问的是一个基于 Unix 的数据库，位于大型机或小型计算机上。这不是普通医生、护士或医疗助理会使用的工具。

Now here in the 90s with EpicCare, they’ve created a Windows application that any PC user can fire up on their Windows machine, and use a graphical interface for their patient interactions in their EMR. And oh yeah, by the way, it’s tied directly into your billing system for your hospital or your health practice. This is all of a sudden really compelling.
现在在 90 年代，EpicCare 创建了一个可以在任何 PC 用户自己的 Windows 机器上启动的 Windows 应用程序，并使用图形界面进行患者互动，这一切都在电子病历（EMR）中。而且顺便提一下，它直接与您的医院或医疗实践的收费系统相连。这突然变得非常有吸引力。

Ben: We’re approaching holy grail here, if you’re a hospital administrator, especially with scheduling. In addition to billing, their scheduling thing is called Cadence. But once you have billing, scheduling, and EpicCare handling the actual clinical part of it, and this is all ambulatory, right? We haven’t gotten to inpatient yet.
Ben: 我们在这里接近了圣杯，如果你是医院管理员，尤其是在排班方面。除了收费，他们的排班系统叫做 Cadence。但一旦你有了收费、排班，以及 EpicCare 处理实际的临床部分，这都是门诊的，对吧？我们还没有涉及到住院部分。

David: Yes. The initial launch of EpicCare, the GUI EMR application, was only for ambulatory, only for outpatient settings.
David: 是的。EpicCare（图形用户界面的 EMR 应用程序）的初始发布仅限于门诊，仅适用于门诊环境。

Ben: Not overnight stays. Yes.
本：不是过夜住宿。是的。

David: Not overnight stays in the hospital.
大卫：不是住院过夜。

Ben: As a non-healthcare person, that’s always how I define what inpatient is.
本：作为一个非医疗行业的人，我总是这样定义住院的。

David: You hear ambulatory, you just hear non-overnight stays. Too confusing otherwise.
大卫：听到门诊，你只会想到不住院的情况。否则太 confusing 了。

Ben: But this is it. Scheduling, billing, and EpicCare on the clinical side for ambulatory. Pretty amazing product that is trajectory-changing for the company. It’s now got enough functionality that it’s not going to stay a small business for long.
本：但这就是它了。预约、计费以及临床侧的 EpicCare（面向门诊的）产品。这是一款非常了不起的产品，对公司的发展轨迹产生了重大影响。现在它已经具备了足够的功能，不会长期停留在小企业层面。

David: So by 1995, they hit $18 million in revenue, up from $1.5 million in 1988.
大卫：到 1995 年，他们的收入达到了 1800 万美元，而 1988 年的收入仅为 150 万美元。

Ben: So pretty phenomenal seven years there were they more than 10x’ed. By most measures you’d look at this and be like, business is going well.
Ben: 所以这七年真是非常 phenomenal，增长超过了 10 倍。按照大多数衡量标准，你会认为这个业务进展得很好。

David: No longer a small Madison, Wisconsin business.
大卫：不再是一家位于威斯康星州麦迪逊的小型企业。

Ben: However, where we were comparing it before was Microsoft. You made the Bill Gates comparison. This company was started, when was it, 1970…?
本：然而，我们之前比较的是微软。你提到比尔·盖茨的比较。这家公司是何时创立的？1970 年……？

David: 1979, so only a couple of years after Microsoft.
大卫：1979 年，所以比微软仅仅晚几年。

Ben: Four years after Microsoft. In 1995, Epic did $18 million. In 1995, Microsoft had gone public and shipped Windows 95 and did $6 billion in revenue.
Ben: 四年之后的微软。1995 年，Epic 收入为 1800 万美元。1995 年，微软上市并发布了 Windows 95，收入达到 60 亿美元。

David: Very different trajectories.
大卫：截然不同的发展轨迹。

Ben: The primary reason here is one is a small, vertical-focused healthcare company, and one is creating the horizontal platform of the future. But it’s worth contextualizing businesses going well by making sure that we stop making the Microsoft comparison from here on out.
主要原因在于一个是专注于医疗领域的小微企业，而另一个正在构建未来的横跨平台。但值得在此之后将业务成功与微软进行比较时进行上下文化。

David: Well, I think I want to come back to it later in the episode and in analysis because yes, Epic is and always will be constrained by being a vertical software provider instead of a horizontal software provider like Microsoft or Google or Oracle or what have you.
大卫：我认为我们应该在剧集后面的部分和分析中再回到这一点，因为是的，埃 pic 始终并且永远都会受限于作为一个垂直软件提供商，而不是像微软、谷歌或甲骨文这样的水平软件提供商。

Ben: Vertical being one industry.
Ben: 垂直是一个行业。

David: Vertical being one industry. However, the one industry that they operate in is 18% of American GDP, so how big can this get is a question we’ll revisit.
David: 他们是单一行业，然而他们运营的行业占美国 GDP 的 18%，所以这个市场能有多大，这个问题我们会重新审视。

Then finally in 2001, they launch the inpatient version of EpicCare, so yes, this is for inpatient hospital stays overnight. Now you finally have the holy grail. You’ve got Chronicles as the one single database. You’ve got EpicCare Ambulatory for all your outpatient clinics. You’ve got EpicCare Inpatient for all your inpatient activities.
然后终于在 2001 年，他们推出了 EpicCare 的住院版本，所以是的，这是针对住院医院留院过夜的情况。现在你终于有了圣杯。你有了 Chronicles 作为单一数据库。你有了 EpicCare Ambulatory 涵盖所有门诊诊所。你有了 EpicCare Inpatient 涵盖所有住院活动。

By the way, again, inpatient activities are probably going to be your majority revenue stream because that’s where the most expensive, most complex care is happening, kind of similar to Medicare is your most important payer relationship because old people is where the most complex, most expensive care is happening, So you’ve got that, and then you’ve got Resolute, the billing system, all single database, all tied together, all built on top of it. If you’re a hospital system administrator, this is the best thing you could possibly imagine.
顺便说一下，再次强调，住院活动很可能是你的主要收入来源，因为那里的护理是最昂贵、最复杂的，有点类似地，老年人是最重要的支付方关系，因为他们的护理也是最昂贵、最复杂的。所以你有这个，然后你还有 Resolute，是一个收费系统，所有内容都在一个数据库中，全部整合在一起，都建立在其之上。如果你是医院系统的管理员，这可能是你所能想象的最好的事情。

Ben: And Epic is really starting to get religion around this point in our future is breadth. Our customer, these hospitals do not want to buy piecemeal solutions. They want to buy everything from one vendor, and they want that one vendor to provide the very best, most integrated experience possible, so we need to continue to orient the company around that philosophy.
Ben: 而从这一点来看，Epic 真正开始信奉的是广度。我们的客户，这些医院不想购买零散的解决方案。他们希望从一个供应商那里购买所有产品，并且希望这个供应商能提供最优秀、最集成的体验，所以我们需要继续将公司定位在这一理念上。

David: Now, right around the same time, actually before EpicCare Inpatient launches, Epic also launches MyChart. This is crazy. If you had asked me before doing research for this episode, when would I guess that MyChart launched, this is an internet-based consumer-facing medical records access interaction platform on the web in a highly regulated HIPAA-regulated industry. I would’ve guessed, I don’t know, 2010 maybe? Mid-2000s at the earliest. No, Epic launched this in the year 2000, which is wild.
David: 现在，实际上是在 EpicCare Inpatient 上线之前，Epic 也推出了 MyChart。这真是疯狂。如果你在为这个节目做研究之前问我，我猜 MyChart 是什么时候上线的，这是一个受 HIPAA 严格监管的互联网面向消费者的医疗记录访问交互平台。我可能会猜，2010 年左右？最迟也是 2000 年代中期。不，Epic 在 2000 年就推出了这个，这真是令人惊讶。

Ben: Right around the dot-com bubble.
本：就在互联网泡沫时期。

David: Yeah, crazy. It’s absolutely wild that they launched this and that their customers launched this.
大卫：是的，太疯狂了。他们推出了这个系统，而且他们的客户还推出了这个系统，真是不可思议。

Ben: And it’s incredibly innovative. It is truly cutting edge. It wasn’t 1994 like Amazon, but the fact that yeah to your point, the medical record thing was being surfaced on the web, it’s pioneering.
本：这非常具有创新性。这确实是前沿技术。虽然不像亚马逊在 1994 年那样，但正如你所说的，医疗记录能够在网络上呈现，这具有开创性。

David: That consumers had direct access to. Well, I want to come back in a minute to how important this is for Epic and their customers, but the origin story of MyChart is fun.
大卫：这使得消费者可以直接访问。不过，我一会儿再回来谈谈这对 Epic 及其客户来说有多重要，但 MyChart 的起源故事很有趣。

It actually started as an outgrowth of what was called Epic Web in 1997, which was a project that they were working on for remote access to the EMR to EpicCare for doctors at home. The idea was like, oh, you’re a doctor. You go home, you wake up in the middle of the night, you’re thinking about a case, and you want to check the medical records, maybe you want to update some…
它实际上起源于 1997 年被称为 Epic Web 的一个项目，这是一个旨在让医生在家远程访问 EMR（电子医疗记录）到 EpicCare 的项目。想法是，比如你是一名医生，你回家后半夜醒来，正在想着一个病例，想要查看一下医疗记录，也许你想更新一些……

Ben: Foreshadowing here of how doctors are going to spend their time in the future.
本：这里预示着医生们将来会如何花费他们的时间。

David: Exactly. Little did they know how much doctors would hate what we’re saying here, but you want to be able to access remotely from your home the medical records of your patients, so they start working on Epic Web.
David: 正确。他们没想到医生们会多么讨厌我们在这里说的内容，但你希望能够在家中远程访问患者的医疗记录，所以他们开始开发 Epic Web。

A young, right out of college programmer is working on this by the name of Sumit Rana. Sumit today is the president of Epic. He goes to the then-president of Epic, Carl Dvorak and says, hey this is good that I’m working on this, but I’m bored. Can you give me something hard to do?
一名刚从大学毕业的程序员名叫苏密特·拉纳正在负责这个项目。如今，苏密特是 Epic 的总裁。他去找当时的 Epic 总裁卡尔·杜瓦克说：“我很高兴在做这个项目，但我觉得有些无聊。你能给我一个难度大的任务吗？”

Ben: This says a lot about the culture of Epic. This is an early career programmer going directly to the president, and that says enough on its own.
本：这充分体现了 Epic 的企业文化。一个初级程序员直接向总裁汇报，这一点本身就说明了很多问题。

David: And the president is running this patient web project.
大卫：而总统正在运行这个患者网络项目。

Ben: Is kind of a computer architecture person himself. And the conversation is about, I want a more interesting project. Can you give something we’re cutting edge to work on?
Ben: 他自己有点像是计算机架构师。而这次的对话是关于，我想做一个更有意思的项目。你们这里有前沿的技术可以让我参与吗？

David: Give me something more challenging. Out of that is born the initial idea for MyChart. I think they started working on it in 1998 and then launched it in the year 2000.
大卫：给我一些更具挑战性的东西。最初的想法就是从那里诞生的，MyChart。我想他们是从 1998 年开始工作的，并在 2000 年推出了它。

Ben: It becomes the first integrated patient portal. Truly, this is a very fair thing to say. This is insanely innovative for as many reasonable barbs get thrown at the company. Some around, oh old technology, and oh the UI is kludgy and all this stuff. Come on. MyChart in 1999 was really cutting edge. People immediately got it. Once you could access your own medical records from home, from your own computer directly without talking to anyone, you were never going back. The world changed overnight.
Ben: 这成为了第一个集成患者门户。确实，说这是非常公平的评价。对于这家公司，这种说法非常创新，尽管有很多合理的批评。有些人认为这是旧技术，用户界面很糟糕等等。别逗了。1999 年的 MyChart 真的很先进。人们立刻就明白了。一旦你可以直接从家中自己的电脑访问自己的医疗记录，而无需与任何人交谈，你就再也不会回头了。世界一夜之间就改变了。

David: It was a little bit like Zillow in real estate. As soon as you can look up how much homes in your neighborhood and your friends and neighbors homes sold for, you’re never going to go back to not being able to do that.
大卫：这有点像房地产领域的 Zillow。一旦你可以查询你所在街区以及朋友和邻居的房子的售价，你就再也不会想回到无法查询的状态了。

Ben: We’re going to have some rich debate later about the pros and cons of EMRs, and are we better off today than we were? But I just can’t fathom being in a world where I don’t have a way to access other than going to the physical building and asking them for my records or placing a call and asking them to call me back.
本：我们稍后将就 EMR 的利弊进行一番丰富的讨论，并思考我们今天是否比过去更好。但我真的无法想象一个没有便捷访问个人记录方式的世界，除了去物理建筑请求查看记录或打电话让他们回电给我。

David: Records used to have to get faxed back and forth when you moved or changed providers. It was brutal. But the other really compelling use case for MyChart, especially when it first launches and even through to today, is managing family members’ care.
David: 转学或更换医疗服务提供者时，病历以前需要通过传真互相传递。那真是非常麻烦。但 MyChart 最具说服力的使用案例，尤其是在最初推出时乃至今天，是管理家庭成员的医疗护理。

You have elderly parents who are using the health system as you do as you get older and you need to help manage that. But you don’t live in the same city. Or even if you do, having MyChart access to family members was huge and starts this whole patient-side virality now for the company.
您有年迈的父母随着年龄增长也在使用医疗系统，您需要帮助管理这些事情。但您并不住在同一个城市。即使住在同一个城市，家庭成员能够使用 MyChart 访问也非常巨大，这开启了公司整个患者端的病毒式传播。

And then for their customers, I imagine initially it was very scary to roll this out. Once they add self-scheduling into MyChart, this becomes the greatest thing for hospitals. The workflow savings of calls that had to happen to scheduling appointments are huge.
然后对于他们的客户来说，我想最初推出这个功能是非常可怕的。一旦将自我预约功能加入 MyChart，这对医院来说就成了最伟大的事情。预约电话所需的流程节省非常巨大。

The other big thing is no-shows. Before MyChart and self-scheduling and the wait list that MyChart manages for patients, if a patient is a no-show that was lost revenue for you as a hospital system. That was a big hole in your daily revenue operations. Now, you can automatically fill that in with another patient on the waitlist.
另一个大问题是爽约。在有了 MyChart 和自助预约以及 MyChart 管理的患者候诊名单之前，如果患者爽约，那就会损失一笔收入，这对医院系统来说是一个很大的收入缺口。现在，你可以通过自动安排候诊名单上的另一名患者来填补这个缺口。

Ben: We’re foreshadowing this, but everyone adopts this. Basically today there are 191 million active users of MyChart. And this is deduplicated. There are active, unique users of MyChart today.
本：我们已经暗示过这一点，但大家都会采用这个系统。基本上，今天 MyChart 有 191 million 活跃用户。这些用户是去重后的，是今天的活跃唯一用户。

David: On the back of this, they launch MyChart in 2000, EpicCare Inpatient in 2001. The company crosses $50 million in revenue. They feel like, okay, we’re finally ready for the big leagues.
大卫：在此基础上，他们在 2000 年推出了 MyChart，2001 年推出了 EpicCare Inpatient。公司的收入突破了 5000 万美元。他们觉得，现在我们终于准备好迎接更大的挑战了。

Ben: Just to contextualize that $50 million of revenue, they’re up to 88 health systems now. They really are starting to penetrate the market just going one by one by one by one to all these different hospital systems and selling them their software.
本：为了让大家理解那 5000 万美元的收入，他们现在已经有 88 个医疗系统了。他们真的开始逐个向这些不同的医院系统销售他们的软件，渗透市场。

David: So they’re ready for the big leagues, and then in 2003 they get a call not just from the biggest player in the biggest league, Kaiser Permanente in California.
大卫：所以他们已经准备好迎接更大的挑战了，然后在 2003 年，他们接到了来自最大联赛中最大玩家——加利福尼亚的凯撒永久保健计划的电话。

But before we tell the Kaiser story, which completely transformed the company…
但在我们讲述凯撒的故事之前，这个故事彻底改变了公司……

Ben: This is a great time to thank friend of the show, Fundrise. The Fundrise team is awesome, and they are big Acquired listeners just like all of you. They’ve been evolving since we first worked together about three years ago. At the time, Fundrise was mostly known as the US’ largest real estate investment platform for retail investors. However, they were watching technology markets get larger and larger than ever thanks to Moore’s Law, and technology of course took over every industry…
Ben: 这是一个感谢节目好友 Fundrise 的好时机。Fundrise 团队非常棒，他们也是像你们一样热衷于 Acquired 的听众。自从三年前我们首次合作以来，他们一直在不断发展。当时，Fundrise 主要被认为是美国最大的面向零售投资者的房地产投资平台。然而，由于摩尔定律，他们注意到技术市场变得越来越大，技术当然也接管了每一个行业……

David: Like healthcare.  大卫：就像医疗保健。

Ben: …and the team there was really feeling like, it really is a shame that all these tech companies are staying private longer, and that means that retail investors can’t get access. So in 2022, they launched their move to bring the democratized model they had developed into venture investing, which was a pretty contrarian idea.
本：……而且那边的团队真的觉得，所有的科技公司都选择保持私有状态的时间更长了，这意味着零售投资者无法获得投资机会。所以，在 2022 年，他们启动了将他们开发的民主化模式引入风险投资的计划，这是一个相当反传统的想法。

David: This had been tried in the past but never really worked. Fast forward to today. Fundrise has invested in great companies like Databricks, Canva, Anduril, Ramp, fellow friends of the show Vanta and Anthropic, and also ServiceTitan, which just went public last December.
David: 这在过去曾尝试过，但从未真正奏效。快进到今天，Fundrise 投资了像 Databricks、Canva、Anduril、Ramp、节目中的朋友 Vanta 和 Anthropic 以及 ServiceTitan 这样的优秀公司。ServiceTitan 最近于去年十二月上市了。

Ben: It is crazy what Fundrise has done. They’ve taken a retail platform that any American can invest in, and gotten pre IPO access to some of the best private companies in the world. They have enabled access to all the value creation that’s been locked up in private companies.
本：Fundrise 做的事情真是令人疯狂。他们将一个普通美国人都可以投资的零售平台，接入了世界上一些最好的私人公司的 IPO 前的访问权限。他们使私人公司中被锁住的所有价值创造都变得可访问。

David: When the ServiceTitan IPO happened, thanks to Fundrise, tens of thousands of regular investors got to celebrate alongside VCs, LPs, and employees. Timing really is everything here. Fundrise is doing this at a moment where thanks to AI, there’s more value than ever being created in the technology sector of the economy.
大卫：当 ServiceTitan 进行 IPO 时，多亏了 Fundrise，成千上万的普通投资者得以与风投、有限合伙人和员工一起庆祝。时机真的很重要。Fundrise 正在利用人工智能技术发展的时刻进行这一行动，此时科技产业创造的价值比以往任何时候都要多。

Ben: You can go check out the full portfolio that Fundrise is building at fundrise.com/venture, and if you are a growth stage founder looking for a great Series-C or later investor, get in touch and tell them that Ben and David sent you. This is a paid endorsement for Fundrise, and all investments can lead to a loss.
Ben: 你可以在 fundrise.com/venture 查看 Fundrise 打造的完整投资组合，如果你是处于成长阶段的创始人，并且正在寻找一位优秀的 Series-C 或更晚轮次的投资人，可以联系他们并告诉他们 Ben 和 David 介绍了你。这是一则付费推荐，所有投资都可能存在损失。

All right, so David, Kaiser Permanente, the biggest of big fishes comes knocking.
好的，所以大卫，最大的大鱼凯撒永久保健公司来找麻烦了。

David: Kaiser Permanente is this fascinating organization that was started and is headquartered here in California, that is a fully integrated “managed care consortium.”
大卫：凯撒永久保健是一家非常有趣的企业，它起源于加利福尼亚，并且总部也设在加利福尼亚，是一个完全整合的“管理保健联盟”。

What that means is that essentially they are both your health plan, your insurance, and your hospital system all in one. It’d be like if an insurance provider married up with a hospital system and said, this is our captive hospital system. You as our members are only going to go get your care here, and we control the whole system. It’s the closest thing that you can have to a single payer here in the country.
这意味着基本上他们既是你的健康计划，也是你的保险，还是你的医院系统。这就像如果一个保险公司与医院系统联姻，并说，这是我们自己的医院系统。作为我们的会员，你们只能在这里接受治疗，我们控制整个系统。这是在这个国家最接近单一支付者的东西。

But importantly, they do also need to work with and interface with Medicare as they have their own Medicare Advantage plan. Patients, customers, once they get older, they transition to Medicare Advantage through Kaiser.
但重要的是，他们也需要与医疗保险合作并对接，因为他们有自己的医疗保险优势计划。患者和客户在年老时会通过凯撒保险公司过渡到医疗保险优势计划。

Ben: Got you.   本：抓到你了。

David: Now, at the time—here we’re in 2003—Kaiser was the largest single hospital system in the entire country. Thirty hospitals, 400+ clinics, 11,000 physicians, and 8½ million patients that are part of Kaiser here in 2003. They decide that they’re going to put out an RFP for a whole new, integrated, entire Kaiser system–wide EMR system.
David: 现在，在 2003 年的时候——当时——凯撒是整个国家最大的单一医院系统。30 家医院，400 多家诊所，11000 名医生，以及 2003 年在这里凯撒系统中的 850 万患者。他们决定要为整个凯撒系统发布一个全新的、集成的 EMR 系统招标书。

Ben: This is when you really should start to think, okay, EMRs are not just medical records, or medical records tied to billing and scheduling.
本：这时候你应该开始思考，电子医疗记录不仅仅是医疗记录，或者与收费和排班绑定的医疗记录。

David: This is the operating system for this industry.
大卫：这是该行业的操作系统。

Ben: Someone described it to me as the nervous system for a healthcare system. You’ve got 20 hospitals, a bunch of doctors, a bunch of administration people. The whole thing is tied together by these unbelievably complex tentacles everywhere piece of software with thousands of different screens and levels of authorization, authentication, roles, and permissions. It is incredibly hairy, and is the single nervous system that the entire organization runs on.
Ben: 有人把它描述为医疗系统的大神经系统。这里有 20 家医院，一群医生，一群行政人员。这一切都通过这些极其复杂的软件触手连接在一起，软件上有成千上万种不同的屏幕和授权、认证、角色和权限级别。这非常复杂，是整个组织运行的单一神经系统。

David: Calling it an operating system is taking it too lightly. It’s like your operating system plus your ERP system plus your applications on top of your operating system. It’s your everything.
大卫：称其为操作系统未免太轻描淡写了。这就像你的操作系统加上你的 ERP 系统再加上你操作系统之上的各种应用程序。这涵盖了你的一切。

Ben: It’s quite reasonable. Even though we refer to these things as EMRs, to start thinking about EMR as a feature for a constituency of the whole system.
Ben: 这是非常合理的。虽然我们将这些事物称为电子病历（EMR），但开始将其视为整个系统的一个利益相关群体的功能是合理的。

David: So in 2003, Kaiser puts out an RFP for a new, again “EHR,” but really new nervous system for all of Kaiser, and Epic wins the deal.
大卫：所以 2003 年，凯撒发布了一份新的 RFP，寻求一个新的“电子健康记录”系统，实际上是为凯撒整个系统打造一个新的“神经系统”，而 Epic 赢得了这份合同。

Ben: Epic was a little company. Just a few years before, they were a $50 million company.
本：Epic 是一家小公司。几年前，他们还是一家年收入 5000 万美元的公司。

David: And after they signed Kaiser, they go to $162 million in annual revenue, so transformative. Probably more than doubled their revenue overnight.
大卫：签约 Kaiser 之后，他们的年收入达到了 1.62 亿美元，这真是变革性的。可能一夜之间收入翻了一番。

Ben: Interestingly—let’s talk prices for a second—the headline number as everyone reports it, is a $4 billion deal. They call it a $4 billion three-year project, and that Epic’s portion is around $400 million. Of course, not all in one year, but the way these things work is there’s a big implementation that costs a bunch of money up front, and then there’s the ongoing license that (I think) eventually would transition to subscription. But at this point it’s licensing to use the software.
Ben: 有趣的是——让我们谈谈价格——据所有人报道的头条数字是一个 40 亿美元的交易。他们称之为一个为期三年的 40 亿美元项目，Epic 的部分大约是 4 亿美元。当然，这并不是一年内的全部金额，但这些事情的运作方式是，有一个前期的大规模实施，成本很高，然后是持续的软件许可（我认为最终会转变为订阅制）。但目前还是按许可使用软件。

It’s just funny to see these headlines because the $4 billion number, not only do they capture many years of the deal and the implementation, but they also roll in there the headcount of the hospital employees that have to do the work, and they roll in there the potential lost productivity from all doctors across the health system who have to ramp on the new software.
看到这些头条新闻真是有趣，因为 40 亿美元的数字不仅涵盖了多年来的交易和实施，还包含了需要完成工作的医院员工的人数，以及整个医疗系统中所有医生因需适应新软件而可能损失的生产力。

David: Which is a real economic impact by the way.
David: 这实际上也产生了经济影响。

Ben: For sure.   本：当然。

David: But it’s not like Epic got $4 billion out of this.
大卫：但这不是说埃佩克从中获得了 40 亿美元。

Ben: No, and I always chuckle because every single one of these numbers looks huge. Multi-billion dollars. Oh, even if it's a small health system, a $300 million project. It ends up resulting in nowhere near that much money to Epic, but this is how the industry has decided to talk about the size of these deals.
Ben: 不，我总是笑一笑，因为这些数字看起来都很大。数十亿美元。哦，即使是一个小一点的医疗系统，一个 3 亿美元的项目。最终结果并没有给埃 pic 带来接近这么多的钱，但这就是这个行业决定用来说这些交易规模的方式。

David: Yeah, it’s funny. We should start talking about the size of Acquired and…
大卫： yeah，真是有趣。我们应该开始谈谈 Acquired 的规模和……

Ben: Fourth and fifth degree tertiary impacts.
Ben: 第四和第五级次级影响。

David: We are a billion dollar business.
大卫：我们是一家市值十亿美元的公司。

Ben: Just think about all the business that our customers do when Acquired listeners… But to your point, it is actually fair. If Kaiser is going to engage in switching their central nervous system over several years, it’s going to be net $4 billion of impact to them.
Ben: 只要想想我们的客户在收购听众时所开展的所有业务……但就你所说的，这也是公平的。如果凯撒计划在未来几年将其中枢神经系统进行转换，这将对他们产生 40 亿美元的净影响。

David: The story of how this goes down is wild. At the time, Kaiser’s two main centers of gravity were northern California and Southern California, and they were almost like separate companies under the Kaiser umbrella. Had different systems, had their own EMRs, different management, of course talked to each other and part of the same parent organization.
大卫：这段故事真是惊心动魄。当时，凯撒的主要重心有两个，分别是北加州和南加州，几乎像是凯撒伞下的两家独立公司。它们各自有不同的系统，有自己的电子病历（EMR），管理方式也不同，当然也会相互交流，并且隶属于同一个母公司。

Ben: Wasn’t there an almost cousin organization that was Northwest? Like this stepchild?
Ben: 难道不是有一个几乎算是表亲的组织是西北的吗？就像这个私生子一样？

David: Yes. I don’t know if it was just Northwest or they had maybe some other smaller regional operations at the time, but they had a Pacific Northwest, small region based in Portland, Oregon. Today actually, Kaiser has large regions through a large part of the country. They’ve grown a lot since then.
大卫：是的。我不确定当时只是西北地区，他们可能还有一些其他较小的区域运营，但当时他们在俄勒冈州波特兰有一个基于太平洋西北的小区域。实际上，今天凯撒在全国很大一部分地区都有大型区域。他们自那时以来已经增长了很多。

But in this small little Portland region, they had started using Epic for their ambulatory clinics, so like not even inpatient stuff in the hospital, but their outpatient clinics. And at the time the northern California and Southern California big factions were battling each other. They’re each trying to develop their own proprietary EMR systems with software consultants, with Accenture and stuff.
但在这个小小的波特兰地区，他们已经开始在门诊诊所使用 Epic 系统，所以不仅仅是医院的住院部分，还包括他们的门诊诊所。当时，北加州和南加州的大派系正在互相争斗，各自试图通过软件顾问（如 Accenture 等）开发自己的专有 EMR 系统。

Ben: There was this era where hospitals thought that EMRs should be their IP that they develop and have a competitive advantage over other hospitals because their EMR was better. I don’t know what the thinking was, but people wanted to own their own EMRs.
本：曾经有一段时间，医院认为 EMR 应该是他们自己的知识产权，可以凭借更好的 EMR 在与其他医院的竞争中获得优势。我不知道他们的想法是什么，但人们都想拥有自己的 EMR。

David: I think there may even have been some pipe dreams of like, oh, we’re going to commercialize this and sell it to other hospitals. It seems like not a core competency that hospitals should be doing.
大卫：我想甚至可能还有一些白日梦，比如，我们 gonna 商业化这个并卖给其他医院。这似乎不是医院应该做的核心竞争力。

Anyway, within the Kaiser system, though, there was a fairly high degree of rotatable of physicians, of doctors. If you were a doctor in Portland with Kaiser Pacific Northwest, and you wanted to move or your family had to move down to California, you could transfer pretty easily to Northern or Southern California Kaiser.
无论如何，在凯撒系统内部，医生的流动性相当高。如果你是凯撒太平洋西北地区的医生，想搬家到加州，你可以很容易地转到加州北部或南部的凯撒医疗系统。

This was happening, and as physicians from the Northwest started coming down to California, they’d feel like, man, what are you guys doing? You’re spending all this money with Accenture and blah-blah-blah, all these consultants to try to roll your own. We’ve got this thing called Epic up in Portland that we’re not even using at the hospital, and it’s way better than the stuff that you’re trying to build.
这确实发生了，随着西北地区的医生开始来到加州，他们会想：你们在做什么？你们花这么多钱在埃森哲和其他咨询公司身上，试图自己开发系统。我们那边在波特兰有一个叫 Epic 的东西，我们连医院都没用上，但比你们试图开发的系统好得多。

Finally after a year or two of this battle between North and South, they finally agree. All right, ceasefire. Let’s come to a truce. We’re going to ditch our competing projects and we’re going to bid this out to third-party vendors. They hold an RFP for a new EMR, for all of Kaiser, one integrated system, and they pick IBM. IBM’s going to come in and do this big $4 billion project for Kaiser.
最终，在南北这场战斗持续了一年或两年之后，他们终于同意停火。好吧， ceasefire，让我们达成停战协议。我们将放弃竞争项目，将这个项目外包给第三方供应商。他们为此发布了一份 RFP，为凯撒医疗集团寻找一个新的 EMR 系统，一个集成系统，并选择了 IBM。IBM 将接手这个价值 40 亿美元的大项目。

Ben: Nobody gets fired for buying IBM. We’re at the end of that era, but it’s still a little that era.
Ben: 没有人因为购买 IBM 而被解雇。我们已经到了那个时代的末尾，但仍然有点那个时代的影子。

David: This is only 2003 here. This bid might’ve even happened before 2003. So IBM comes in and the project fails. Doesn’t work.
大卫：这只是 2003 年的情况。这个投标甚至可能发生在 2003 年之前。于是 IBM 进来，项目失败了。没有起作用。

Ben: This is not uncommon, especially think about ERP, the number of times you’ve heard oh failed ERP implementation and some CEOs explaining on enterings call. Yeah, we’d lost hundreds of millions or billions of dollars and we actually didn’t even switch systems. This thing does happen in the hospital world, too, and Epic has bet the whole company on having a reputation for we don’t have failed implementations. And that wins deals.
这并不罕见，尤其是考虑到 ERP，你听到过多少次失败的 ERP 实施案例，一些 CEO 在财报电话会议上解释说，我们损失了数亿甚至数十亿美元，而且我们甚至没有切换系统。这种情况在医疗界也发生过，而 Epic 公司则押注整个公司声誉在于我们没有失败的实施案例。这赢得了合同。

David: Totally. I think this is one of the most important reasons why their customers love them.
大卫：完全同意。我认为这是他们客户喜欢他们的一个最重要的原因。

Ben: We’re going to say this a bunch of times in the episode. Their customers love them. When we say customer, we mean hospital CEO, CIO (the Chief Information Officer), and CFOs. When we refer to their customers, that’s who we’re talking to.
Ben: 在这一集中我们会多次提到这一点。他们的客户非常喜欢他们。当我们提到客户时，我们指的是医院的 CEO、CIO（首席信息官）和 CFO。当我们提到他们的客户时，就是指这些人。

Obviously, the Chief Medical Officer and all of the physicians, nurses, and care folks are a part of that. But a part of my research has revealed the customer is the hospital administration.
显然，首席医疗官以及所有的医生、护士和护理人员都是其中的一部分。但我的研究还揭示出，客户其实是医院管理层。

David: I doubt that’s even a controversial statement probably at Epic themselves. I think they consider the customer to be the CEO, CIO, and CFO of their customers.
戴维：这大概甚至不是一个有争议的陈述，可能在 Epic 公司内部也是如此。我认为他们认为客户的 CEO、CIO 和 CFO 都是他们的客户。

So the IBM project fails, and maybe it’s worth another word on that too. It’s not like this doesn’t impact the physicians and the staff of the hospitals and poor performance for the hospital as is in the case of this failed IBM implementation. Massive detriment to the physicians. This must have really, really sucked for them. They want stability too.
IBM 项目失败了，也许我们也可以再谈谈这个。这并不是说这不会影响医生和医院的员工，以及医院的糟糕表现，就像这个失败的 IBM 实施案例一样。这对医生来说是一个巨大的打击。这一定对他们来说真的很糟糕。他们也希望有稳定性。

Ben: And the physicians provide the value at hospitals. Therefore you need to make the physicians happy to retain your administration job. They have the leverage in the organization because they provide the core competency. But still you’re not going in and pitching the doctors when you’re going in and trying to land a customer.
Ben: 医生在医院提供价值。因此你需要让医生满意以保留你的管理职位。他们在组织中具有杠杆作用，因为它们提供了核心竞争力。但在你试图赢得客户时，你并没有直接向医生推销。

David: You could think of a hospital almost like a media company. The doctors and the nurses and the clinicians are the on-air talent. The on-air talent are not the ones at Disney or Universal or wherever who are making the business decisions.
David：你可以把医院想象成一家媒体公司。医生、护士和临床人员就像在镜头前的 talent。这些 talent 并不是在迪士尼、环球或者其他地方做出商业决策的人。

Ben: And in this case, the medical staff is involved, but they’re not the decision maker.
本：在这种情况下，医疗人员参与其中，但他们不是决策者。

David: So, okay, Kaiser’s now got to rebid this project. And by this point in time, enough Portland doctors had come down to California and sung Epic’s praises. They’re like, all right. We should take this little company seriously. They start the RFP and it comes down to Epic and their big main rival Cerner.
大卫：所以，现在凯斯尔得重新投标这个项目。到这个时候，已经有足够的波特兰医生来到加州，称赞了 Epic 的系统。他们说，好吧，我们应该认真对待这家公司。他们开始制定 RFP（请求报价），最终竞标的是 Epic 和他们的大竞争对手 Cerner。

Now, we haven’t really talked about Cerner so far in this episode. Part of Oracle today, as we will get into later. Cerner was a much bigger company.
现在，我们在这集里还没有真正提到 Cerner。它是一个更大的公司，我们稍后会谈到它现在是 Oracle 的一部分。

Ben: Interestingly, started right around the same time, right?
Ben: 有趣的是，差不多同时开始的，对吧？

David: Yeah. Wow, I think it started the same year as Epic, right? 1979.
大卫：是的。我觉得是从 1979 年开始的，和 Epic 同年，对吧？

Ben: Yup, by Neal Patterson.
本：对，由 Neal Patterson 创立。

David: By Neal Patterson in Kansas City, Missouri. Unlike Epic, which took the no venture capital, no acquisitions, single platform, stay private forever route, Cerner took lots of acquisitions, raise capital, go public, get big route.
由 Neal Patterson 在密苏里州堪萨斯城创立。与 Epic 不同，Epic 采取了不寻求风险投资、不进行收购、单一平台、永远保持私有化的路线，而 Cerner 则采取了大量收购、筹集资本、上市、变大的路线。

Ben: Which could have worked too.
本：这也可能行得通。

David: It did work too.
大卫：它确实也奏效了。

Ben: It did work for a long time.
Ben: 确实有一段时间是有效的。

David: At this point in time, Cerner is almost a billion dollar a year revenue business. They’re a public company way, way, way bigger. They’re international, et cetera. The RFP comes down to the two of them.
大卫：到目前为止，Cerner 的年收入几乎达到十亿美元级别。他们是一家规模大得多的上市公司，而且是国际性的，等等。RFP 最终只发给了他们两家。

Ben: It’s worth saying before they were acquired by Oracle, it was a merger of 24 different companies. Put a nice little wrapper on it and call it Cerner, but a lot of companies along the way.
Ben: 在被甲骨文收购之前，这是一家由 24 家不同公司合并而成的公司。给他们加上一个漂亮的包装，称之为 Cerner，但一路上有很多公司。

David: A different path than the one Judy took, let’s say. But that’s not to knock it. It is, and especially back then, was a good, really competitive product. The obvious choice for Kaiser here in 2003 would’ve been to go with Cerner.
大卫：走的是一条与朱迪不同的道路，这样说吧。但这并不是说它不好。在当时，这确实是一款很好的、非常有竞争力的产品。2003 年，对于这里的大都会医疗集团来说，选择 Cerner 显然是最明显的选择。

And they actually try to go with Cerner. Supposedly at one point, they come to both companies, to Cerner and Epic, and they say, look. Cerner, we want to go with you for inpatient in the hospital since that’s your bread and butter. This is the most important thing. This is the big business. We trust you. You’ve been around forever.
他们实际上试图与 Cerner 合作。据说他们同时向两家公司，Cerner 和 Epic，提出了合作意向，并说，Cerner，我们想与你们合作进行住院服务，因为这是你们的强项。这是最重要的业务。这是大生意。我们信任你们，你们已经存在很长时间了。

Epic, hey, you’ve got inpatient now, but you only just launched that in 2001. You’re new at this. You are good at ambulatory, at outpatient. You’re doing a really good job for us in Portland. We want to split the baby here and do one system with Epic for our outpatient clinics and one system with Cerner for our inpatient clinics.
Epic，你们现在有住院服务，但你们直到 2001 年才刚刚推出这项服务。你们在这方面是新手。你们擅长门诊服务。你们在波特兰为我们做的很好。我们想在这里分而治之，使用 Epic 系统来管理我们的门诊诊所，使用 Cerner 系统来管理我们的住院诊所。

Ben: Oh yeah. That always works.
本：哦 yeah。这总是行得通。

David: And Judy says no. That is a bad choice. That is the wrong choice to make. I don’t care if you go with us or them, but to do the right thing for your patients, for your whole system, to make billing work, have this all function correctly, and have patient records transferred between your ambulatory clinics and your hospitals, which you really, really need, you should just pick one of us.
大卫：朱迪说不行。这是一个糟糕的选择。这是一个错误的选择。无论你选择我们还是他们，但为了你的患者，为了整个系统，为了使账单工作正常，让这一切都能正确运行，以及在你的门诊诊所和医院之间转移患者记录，这是你真正需要的，你应该选择我们中的一个。

Now, this was a little self-serving on Judy’s part because Cerner was not good at ambulatory.
现在，这在一定程度上是朱迪的自我炒作，因为 Cerner 在门诊服务方面并不出色。

Ben: . It’s a calculated high risk decision.
本：这是一项经过计算的高风险决策。

David: However, definitely super ballsy to do this. But she knew that Epic had a good product in both. The problem was just that their inpatient product was still new, so didn’t have trust yet in the marketplace. But she’s still a pipsqueak. Cerner’s a billion in revenue at Epic is somewhere slightly north of $50 million at this point in time.
David: 然而，这样做确实非常大胆。但她知道 Epic 在两者上都有很好的产品。问题在于他们的住院产品还很新，所以在市场上还没有建立起信任。但她还只是个小角色。Cerner 的收入是十亿美元级别，而 Epic 目前的收入略高于五千万美元。

They go a little further in the process. At one point there’s a technical due diligence meeting where Kaiser asks both companies to come in and present to them about how their systems are going to handle all the volume of concurrent data transactions that Kaiser has. Remember, 8½ million patients, 11,000 physicians, is a high volume system here.
他们在过程中走得更远一些。在某个阶段，有一个技术尽职调查会议，凯撒要求两家公司前来向他们展示其系统将如何处理凯撒所面临的大量并发数据交易。请注意，8.5 百万患者，1.1 万名医生，这是一个高流量系统。

Ben: And listeners, this is a great story. This is the 11th hour of the deal. This is, hey, we’re pretty close to a decision, but we haven’t made it yet. Can you both come to the same building, sit in different conference rooms, and throughout the day we’re going to bounce back and forth and keep spending an hour with each of you, formulate some questions from hearing the other pitch, and then come back and ask you those questions.
Ben: 而听众们，这真是一个精彩的故事。这是交易的第十一小时。嘿，我们离做出决定已经很接近了，但还没有最终确定。你们俩能否都来到同一栋楼，在不同的会议室里坐下来，然后一整天里我们来回交流，分别花一个小时与你们每个人交谈，从听对方的提案中提炼出一些问题，然后再回来问你们这些问题。

If you’re on one team or the other, you can learn through the questions, what is being pitched in the other room and why am I suddenly being grilled on this new topic.
如果你在一方团队，你可以通过问题学习另一方在房间里提出了什么，并且为什么我突然被问到这个新的话题。

David: The Epic team is doing their planning and getting ready for all the preparation for this really big meeting. The team had decided that the way they were going to handle this question was to do a theoretical presentation about how Epic’s architecture worked, the single system, and theoretically how much load could the system handle all at once?
大卫：Epic 团队正在制定计划并为这次非常重要的会议做所有准备工作。团队决定处理这个问题的方式是进行一个理论性的展示，介绍 Epic 的架构是如何工作的，单一系统能够一次性处理多少负载？

The story is that Carl Dvorak (the president) flew into California the night before the pitch, meets with the team, sees this plan, and is like, guys, no. We need to model out in Excel exactly what Kaiser’s transaction flow is going to be throughout the day in this system and how our system will process it, and prove to them that we have far in excess bandwidth capability to handle their system and it’ll never go down.
Carl Dvorak（总裁）在提案前一天飞到了加州，与团队会面，看到了这个计划后说，伙计们，不行。我们需要在 Excel 中详细模拟整个系统一天中 Kaiser 的交易流程以及我们的系统将如何处理这些交易，并证明我们有远超他们所需的带宽能力来处理他们的系统，而且绝不会宕机。

Ben: Because I think they had done it at a theoretical formula level. But Carl knew that Epic had the advantage here, that they actually could, if they played it all the way out and really built out the spreadsheet show, actually we’re going to be more performant for you.
Ben: 因为我认为他们是在理论公式层面做的。但卡尔知道 Epic 在这里有优势，如果他们把这整个过程都走一遍，真正构建出电子表格展示，我们实际上会对你更有优势。

David: So he and the team pull an all-nighter the night before the presentation. I don’t know if Judy was there as well—I assume she was too—come in, and they show the model during these meetings that Kaiser is having back-and-forth between the two teams.
所以他和他的团队在演示前一天通宵工作。我不知道朱迪是否也在场——我假设她也在场，然后他们在这次会议中展示了模型，这是凯撒与两个团队之间来回讨论的模型。

As the days go on, it becomes really clear that Cerner has not done a similar level of modeling and can’t actually prove to Kaiser that their system is going to be able to handle the transaction flow. I think this was the moment when the tide turned, that Epic was like, oh yeah, we’re going to win this thing.
随着日子的推移，很明显 Cerner 没有进行类似的建模工作，也无法向凯撒证明他们的系统能够处理交易流量。我认为这是转折点，Epic 意识到他们将赢得这场竞争。

Ben: But it still wasn’t obvious right away. I think they earned big points there. But my understanding is that Kaiser still went to Cerner and said, we’re interested. Can we do an equity deal on top of this? Can we take part of the company in exchange for basically giving you this big deal? I think Cerner said yes.
Ben：但一开始并不明显。我认为他们在这一点上获得了很大的分数。不过据我了解，凯撒还是去找了 Cerner，说我们有兴趣。我们可以在这个基础上进行股权交易吗？我们可以用部分公司的股份来换取你给我们这个大项目吗？我认为 Cerner 答应了。

David: The story as we heard it at least, is that at the last minute then right before the decision, Kaiser came to both companies and said, hey, we’d really warrant in your company. We’re the biggest health system in America. This is the biggest contract you’re going to get. We want some equity in your companies for working with us. Apparently, Cerner did offer them 10% of the company for this deal. That’s how important this was.
大卫：据我们所知的故事，在最后一刻，在做出决定之前，凯撒同时来到了这两家公司，说：“我们真的很希望你们能加入我们的公司。我们是美国最大的医疗系统。这是你们能拿到的最大合同。你们与我们合作，我们希望能在你们的公司获得一些股权。”据说，辛辛那特公司为这个交易提供了他们公司 10%的股权。这说明这个交易是多么重要。

Ben: So they come to Epic and they say…
本：所以他们来到 Epic，并说……

David: Come to Epic and they’re like, well what do you have to say about that? Judy’s like, no. We’re not going to do it. We’re not going to do it for you. We’re not going to do it for anybody. And it’s the wrong thing to do. If we did it for you, we’d have to do it for all our big customers, and then that would turn out poorly for you too. So absolutely not. And they still picked Epic in the end.
David: 来到 Epic，他们就说，好吧，你有什么要说的？Judy 回应说，不。我们不会为你做这件事。我们不会为任何人做这件事。这是一件错误的事情。如果我们为你做，我们就必须为我们的大客户都做，那样对你也不好。所以绝对不行。但他们最终还是选择了 Epic。

Ben: Through that, through the architecture bake-off and through the know you have to pick one of us. Epic still won out and stuck to their guns all the way through that negotiation.
Ben: 就是通过那场架构竞标，你们必须从中选择一个。Epic 最终还是胜出，并在整个谈判过程中坚持己见。

David: Which I think really should just tell you how important the stability and continuity of the system across inpatient, outpatient, and billing is, because Epic is the only one that can offer that.
大卫：我认为这真的应该告诉你系统在住院、门诊和收费方面的稳定性和连续性有多么重要，因为只有埃 pic 系统能够提供这一点。

Ben: By the way, earlier when I said 24 different companies merged together to create Cerner, I forgot that this chart that I’m looking at predates when Cerner then bought Siemens. So then there are another 12 companies that had merged together to become Siemens that merged also into Cerner.
本：顺便说一下，刚才我说 24 家不同的公司合并成立了 Cerner 时，忘记了一点，我正在查看的这张图表是在 Cerner 收购 Siemens 之前就存在的。因此，还有另外 12 家合并成为 Siemens 的公司也合并进了 Cerner。

David: We’re going to come back to the Siemens acquisition in a minute. I think that was 2014 when that happened. But yeah, this is key. This is why Epic wins.
大卫：我们一会儿再回到西门子收购的事情上。我记得那是 2014 年。但确实，这就是关键。这就是 Epic 取胜的原因。

So they win the deal, basically doubles or triples revenue overnight. The LA Times writes about the deal when it gets announced. “Because of its scope, the Kaiser Epic System could become the Model T of its industry. Not the first of its kind, but the first to reach masses of people.”
所以他们赢得了这笔交易，基本上一夜之间收入翻倍或翻三倍。当这笔交易宣布时，《洛杉矶时报》进行了报道：“由于其规模，凯撒 Epic 系统有可能成为其行业的 Model T。不是第一款此类产品，但却是第一款能够惠及大量人群的产品。”

Once this happens, Epic gets elevated to the new gold standard. If you’re a hospital system, if you’re a CIO or a CEO looking to rebid your EMR, well Kaiser, the biggest system in the world just chose Epic, and they chose it over all of these reasons not to. There must be something really good in there, like of course you’re now going to consider Epic. And of course Epic is going to perform really well in these evaluations.
一旦这种情况发生，Epic 将成为新的金标准。如果你是一家医院系统，如果你是一位 CIO 或 CEO，正在重新招标 EMR，那么凯撒（Kaiser），世界上最大的系统，刚刚选择了 Epic，并且选择了它而不是这些不选择它的所有原因。其中肯定有很好的东西，当然你也会考虑 Epic。当然，在这些评估中，Epic 也会表现得非常好。

Ben: It helped a little bit at first, but after the go live, a few years in, after the whole implementation took place, and they didn’t tip over, and it did go well, that was really when the floodgates opened in that 2006, 2007, 2008 timeframe.
本：刚开始有一点帮助，但在上线后，实施过程结束后，几年的时间里，系统没有崩溃，运行得还不错，那才是 2006 年、2007 年、2008 年这段时间里闸门真正打开的时候。

David: So by 2007, Epic has hit 500 million in revenue, so another 3x what they were doing once they added Kaiser, and 8x what they were before Kaiser, almost 10x what they were before Kaiser. They’re really starting to transform into a big company.
大卫：到 2007 年，Epic 的收入达到了 5 亿美元，比加入凯泽之后的收入又增加了 3 倍，比加入凯泽之前增加了 8 倍，几乎是之前的 10 倍。他们真的开始转型成为一家大公司。

Ben: I spoke with one former employee and I was asking what were the inflection points in the company. This employee said, oh, after we won the Kaiser deal, we had been hiring like 10 kids a month out of college, and it now felt like hundreds a month were just flowing into the doors so we could scale.
本：我与一位前员工交谈，询问公司在哪些关键时刻发生了变化。这位员工说，我们在赢得凯撒医疗集团的合同后，每个月从大学毕业的学生招聘人数达到了十几人，而现在每个月似乎有成百上千的人加入公司，这样我们才能扩大规模。

David: Which will bring us in a minute to Epic’s epic, shall we say, Verona, Wisconsin campus.
大卫：这将把我们带到埃克希普在威斯康星州的韦罗纳校区，可以说是埃克希普的“罗密欧与朱丽叶”。

Ben: Yeah, and one thing, just for our storytelling narrative there we skipped over, was there’s another thing that happened in the early 2000s that reads a little bit as an alternate history for what could have happened at Epic.
Ben: 是的，还有一件事，虽然我们在故事叙述中跳过了，但在 2000 年初发生了一件事，这件事读起来有点像是 Epic 可能发生的另一种历史。

Imagine you’re a small company. A big company comes to you and says, can we co-develop a new product together? You can distribute it to your customers, we’ll distribute it to our customers under our brand name and everything, but you get some of that revenue. We’ll build this with you and it really will charge your business up.
想象一下你是一家小公司。一家大公司来找你，说我们可以共同开发一款新产品吗？你可以将它分发给你的客户，我们则在我们的品牌下分发它，但你也能从中获得一些收入。我们将与你一起开发这款产品，这真的会推动你的业务发展。

If you don’t know any better and you’ve never done it, it sounds appealing. Maybe we should do that. There are many instances of it working, so that’s extra tempting. My favorite weird example of this in history of it not really working is the HP iPod. Do you remember this?
如果你以前没有做过，听起来会很有吸引力。也许我们应该试试。有很多成功的例子，所以这更是诱人的。我最喜欢的历史上不太成功的奇特例子是惠普的 iPod。你还记得吗？

David: Oh yeah, that’s right. I do remember this. I think I might have had one. No, I have one of the U2 iPods, the red and black one.
大卫：哦对，我记起来了。我想我可能有一个。不，我有一个红色和黑色的 U2 iPod。

Ben: Listeners, Google it. It’s this really odd thing. It’s an HP brand on the back of an iPod that tells you all you need to know about what a weak position Apple was in at the time, that they were willing to let HP put their brand on something entirely created by Apple, to get HP’s distribution, and get some cut of that revenue. Of course, it would’ve bootstrapped their ecosystem since it used iTunes and all that.
Ben: 听众们，谷歌一下。这真是件奇怪的事情。这是一款 HP 品牌的产品，贴在 iPod 背面，告诉你当时苹果是多么弱势，他们愿意让 HP 在其产品上使用自己的品牌，只是为了获得 HP 的分销渠道，并从中分一杯羹。当然，这也有助于他们生态系统的发展，因为这款产品使用了 iTunes 等。

That’s basically what happened here. Philips, the Dutch company, comes to Epic and says, we want to do something focused on the radiology segment. You do a lot of the development work. We have the customer relationships and distribution.
这就是这里发生的事情。荷兰公司飞利浦来到 Epic，说我们想专注于放射学领域。你们来做大部分开发工作。我们有客户关系和分销渠道。

David: Because they’re probably selling the machines.
大卫：因为他们可能在卖这些机器。

Ben: Yes. We, Phillips, will get a license to Epic’s whole IT system. Everything that you already sell we want to sell also, and we’re going to market that as Philips’ Externity Enterprise to our customers. They’re going to buy a Philips-branded version of Epic.
Ben: 是的。我们将从菲利普斯获得 Epic 整个 IT 系统的许可。你们现在销售的所有产品我们也都想销售，并且我们将这些产品以飞利浦 Externity Enterprise 的名义推向市场。客户将购买带有飞利浦品牌的 Epic 版本。

David: Interesting. I imagine Philips probably has a lot of customers, not in America too, like in Europe, so this is a way to go international.
大卫：有趣。我想飞利浦肯定有很多客户，不仅在美国，还有在欧洲，所以这是一个走向国际市场的途径。

Ben: Right, so Epic starts hiring people in the Netherlands. They build up this team. They spend multiple years or at least a year building it out. I think they even launch it. The whole thing ends up folding. Within a year or two of coming out, it was a really expensive detour, and the company develops this intense scar tissue for partnerships.
Ben: 好的，所以 Epic 开始在荷兰招聘人员。他们组建起这个团队，并花费了几年时间，至少是一年的时间来完善它。我想他们甚至推出了这个项目。但整个项目最终失败了。在推出一年或两年后，这变成了一次非常昂贵的偏离，公司也因此对合作伙伴关系产生了强烈的抵触情绪。

Partnerships at this era to the Epic team means: (a) stuff I can’t control outside my organization, (b) big risk, (c) never in our history do we have an example of it working. This is an uncontrollable dependency, and they internalize this scar tissue as stay focused on what we can control, go directly to the customer, don’t try to do any fancy partnership integration stuff with other people.
在这个时期，与 Epic 团队的合作意味着：(a) 我无法控制的外部组织的事情，(b) 高风险，(c) 在我们历史上从未有过成功的先例。这是一种无法控制的依赖关系，他们将这种经历内化为专注于我们能控制的事物，直接面向客户，不要尝试与他人进行任何复杂的合作伙伴集成。

That’s oversimplifying it, but I think it’s still reasonable to say that some of the DNA of what Epic would become—and they would take tons of errors for this closed, not interoperable, blah-blah-blah—stems from this failed partnership.
这有些过于简化了，但我想说，Epic 会成为什么样的部分——他们为此付出了大量的错误，这些错误源于一个封闭且不兼容的系统——确实可以从这次失败的合作中找到根源。

David: With Philips, totally. They’re now partnering again, finally, but 15–20 years later.
David: 与飞利浦完全是这样。他们现在终于再次合作了，但已经是 15 到 20 年之后了。

Ben: Yes. Thanks to Health API Guy for the tip on that.
Ben: 是的。感谢 Health API Guy 提供的那个提示。

At this point in the late 2000s, Epic is eyes on the prize, we’re building everything ourselves, we can get big customers on our own, we can stand firm and not negotiate, not have to give up pieces of our company, the price is the price, and we know that we’re going to deliver. So it’s time to invest in our future. How do they invest in the future?
在这个 2000 年代后期，Epic 目标明确，我们自己建造一切，我们可以独自获得大客户，我们可以坚持立场而不进行谈判，不必出让公司的一部分，价格就是价格，我们知道我们会交付。所以是时候投资我们的未来了。他们如何投资未来？

David: The Verona campus. For the probably minority of you listening, who know anything about Epic as a company or been involved with them in the past, if you have, you almost certainly know about their corporate campus.
大卫：弗罗纳校区。对于了解埃 pic 公司或以前曾与他们有过接触的少数听众来说，如果你有，几乎可以肯定你听说过他们的公司总部校园。

There are two stories of how the campus came to be. First is Judy’s son, by this point in time, is actually working at Microsoft in Redmond as a developer. Judy and Carl had always been inspired by Microsoft’s way of doing things.
校园的由来有两个故事。第一个故事是，到这个时候，朱迪的儿子已经在微软雷德蒙德分部担任开发人员。朱迪和卡尔一直被微软做事的方式所启发。

One time when Judy’s visiting her son, she’s like, hey, can you go give me a tour of the campus in Redmond? We’re thinking about expanding. We’re outgrowing our space. I want to see what it’s like there. She’s really impressed by Redmond as I think anybody who goes there would be.
有一次，朱迪去看儿子时，她说：“你能带我去雷德蒙德的校园转转吗？我们正在考虑扩大规模。我们的空间已经不够用了。我想看看那里是什么样子。”她对雷德蒙德的印象非常好，我想任何人都会有同感。

Ben: Especially in this era. It was pre-Googleplex. It was the fairytale tech campus.
Ben: 尤其是在那个时代。还没有谷歌园区，那是一个童话般的科技园区。

David: It was Google before Google. She’s like, this is like a college campus here. The atmosphere that you’ve got.
David: 这是谷歌之前的时代。这里就像一个大学校园，你能感受到那种氛围。

Ben: Sports field, tons of buildings, all of them are pretty short—two, three, four storeys—a lot of outdoor space, walking space, everyone gets an office. This is perfect.
Ben: 运动场，很多建筑，都是两三层楼高的短建筑——有很多户外空间，走路的空间，每个人都有办公室。这 perfect。

David: Judy comes back and basically copies the campus strategy of Microsoft, almost exactly.
大卫：朱迪回来后，基本上复制了微软的校园策略，几乎一模一样。

Ben: They had been in that renovated schoolhouse. If you think about where they came from, then what they now have the opportunity to build, they had renovated the schoolhouse to be nice, but…
他们曾在那所翻新的学校里。如果你想想他们是从哪里来的，然后他们现在有机会建造的东西，他们只是把学校翻新了一下，使其变得不错，但…

David: That was well before they were a half-a-billion-dollar-a-year revenue company.
大卫：那还是他们还没有成为年收入超过五千万美元的公司之前。

Ben: Exactly.  本：正是这样。

David: So she goes out and buys 1000 acres of farmland in Verona, Wisconsin, which just like Redmond, is a bucolic-looking suburb about half an hour outside the city in Madison. Or I guess maybe Redmond was bucolic before Microsoft, but got it built up. But just like Microsoft owns Redmond, Epic owns Verona, spiritually. So they build this incredible campus there.
大卫说：“于是她出去在威斯康星州的韦罗纳买了 1000 英亩的农田，韦罗纳就像雷蒙德一样，是一个田园风光的卫星城，距离麦迪逊市区大约半小时车程。或者说，也许在微软之前，雷蒙德就是田园风光的，但微软把它建设起来了。就像微软拥有雷蒙德一样，埃 pic 在韦罗纳拥有着精神上的所有权。所以他们在那儿建了一个令人惊叹的校园。”

Ben: And what is very different about it from Microsoft is it is not utilitarian the way that the Microsoft buildings were. A thing that was already happening at Epic was this fairytale whimsical thing that you can see in their product names. But David, what was the story we heard about the schoolhouse fireplace?
本：与微软不同的是，它不像微软的建筑那样实用主义。在 Epic 已经发生的事情是你可以从他们的产品名称中看到的那种童话般的、充满幻想的事情。大卫，我们听说的学校教室壁炉的故事是什么？

David: Okay, so this is the second story of the Epic campus. Like you said, Ben, before Verona, the headquarters was in an old school building in Madison that they’d bought and renovated. As they were renovating it, the designers decided that in one of the main conference rooms they were going to put a fireplace in there to make it feel more homey.
大卫：好吧，这是 Epic 园区的第二个故事。就像本说的，在韦罗纳之前，总部是在麦迪逊的一所他们买下来并翻新的旧学校建筑里。在翻修的过程中，设计师们决定在其中一个主要的会议室里放一个壁炉，让这个地方感觉更像家。

Ben: Like a Wisconsin lodge.
本：就像威斯康星州的狩猎小屋。

David: I don’t even know if the designers did that, but I think Judy and the company were like, well this feels like a Wisconsin Lakes lodge. Let’s lean into it. They decorated it like a lodge. They brought snowshoes, furs, and an axe that they put on the wall and stuff. It ends up becoming the most popular room in the building. Anytime customers are coming to Madison, they always want to meet in the lodge conference room. Now they’re building this new campus institute, he’s like, oh, well let’s take the lodge idea and…
大卫：我不知道设计师们是否真的这么做了，但我觉得朱迪和公司觉得这就像一个威斯康星湖畔小屋。让我们利用这个想法。他们把房间装饰成了小屋的样子，带来了雪鞋、毛皮和一把挂在墙上的斧头之类的。结果这个房间成了大楼里最受欢迎的房间。每当客户来到麦迪逊，他们总是想在小屋会议室内见面。现在他们正在建设一个新的校园研究所，他说，哦，好吧，让我们把小屋的想法……

Ben: Really blow it out.
Ben: 真的要把它吹大。

David: Maximize it.  大卫：最大化它。

Ben: So they inject this fairytale-ness times 10 when they’re building out the new campus. They hire the same firm that did the Disneyland California Adventure renovation in 2008.
本：所以在建设新校园时，他们注入了童话般的元素十倍之多。他们聘请了负责 2008 年迪士尼加州冒险乐园改造的同一公司。

David: I think it’s even more on the nose on that. They hired two architecture firms. One is that, and then they also hired the firm that built a lot of the Redmond campus for Microsoft.
大卫：我认为这一点在那里的表现更为明显。他们聘请了两家建筑公司。一家是这样的，另一家则负责了微软在雷德蒙德的大部分园区建设。

Ben: Oh, is it really? Wow. And it’s crazy. It’s Alice in Wonderland stuff. It’s Harry Potter–inspired stuff. It’s Wizard of Oz–inspired stuff. Just google pictures of the Verona campus for Epic, and we’ll link to some in the show notes too. It’s bananas. But it is extremely attractive to new hires coming out of college, who want to feel like they’re still in college, and want to go work for a company that seems fun and interesting.
Ben: 哦，真的吗？哇。这真是疯狂。这就像《爱丽丝梦游仙境》的东西。这像是《哈利·波特》启发的东西。这像是《绿野仙踪》启发的东西。只要在谷歌上搜索 Epic 的弗罗纳校园的照片，我们还会在节目备注中链接一些。这真是疯狂的。但这对刚从大学毕业的新员工来说极具吸引力，他们希望感觉自己仍然在大学里，希望加入一个看起来有趣且令人感兴趣的公司。

Epic is this two-sided culture that seemed to play well together somehow, this goofy, whimsical fairytale thing and this hard driving win at all costs, performance-oriented, fierce competitor. It just is both. To understand the company, you have to hold in your head that the DNA is both of those things concurrently, and I think it’s because that’s what Judy is.
Epic 是一个似乎能很好地结合在一起的两面文化，一边是滑稽 whimsical 和童话般的 thing，另一边是不惜一切代价追求胜利、以绩效为导向、激烈的竞争对手。它就是两者兼备。要理解这家公司，你必须同时在脑海中容纳这两种 DNA，我认为这是因为 Judy 就是这样的一个人。

David: Yes, 100%. That is completely spot on. I had in my script here the question of all this is why on the campus, and that is exactly why. We are hiring super smart, young, hungry, new college grads. How are we going to attract them to Verona, Wisconsin? Well we are going to create a paradise for them.
大卫：是的，完全正确。我的剧本里有这样一个问题，这一切为什么发生在校园里，正是这个原因。我们正在招聘非常聪明、年轻且充满野心的新大学毕业生。我们如何吸引他们来到威斯康星州的韦诺纳市？我们将为他们创造一个天堂。

Ben: Some interesting stats. It’s 1700 acres, 410 of them are the campus, the rest is the farm. It now covers 89 buildings. There are 4 indoor auditoriums with 18,000 seats total. The big one, Deep Space, is the world’s largest subsurface auditorium.
一些有趣的统计数据。总面积是 1700 英亩，其中 410 英亩是校园，其余的是农场。现在它包括 89 栋建筑。有 4 个室内剧院，总共可容纳 18,000 个座位。其中最大的一个是“深空”，它是世界上最大的地下剧院。

There are 11,400 seats. This is an auditorium. This is two Radio City Music Halls full of people smashed together in one giant auditorium underground on a corporate campus. The number of seats is much closer to a Chase Center. It’s much closer to a basketball arena than it is to any other auditorium that I can think of. It goes down 74 feet beneath the surface.
有 11400 个座位。这是一个礼堂。这相当于把两个无线电城市音乐厅的人挤在一个巨大的地下礼堂里，位于一家公司的园区内。座位数量更接近于 chase center。它更像是一个篮球 arena，而不是我想到的其他任何礼堂。它向下延伸了 74 英尺。

The whole logic behind it is when they built it, they thought, oh we’ll never grow to 11,400 people. We can have our all hands in here, no brainer. But this can also be the place where we have all of our customers and our whole ecosystem can come here. Of course, now they don’t actually fit in there because they’ve outgrown it. Not even all their employees can come to all hands there.
其中的全部逻辑是在构建它的时候，他们认为我们永远不可能增长到 11400 人。我们可以在这里所有人手齐上，毫无疑问。但这也可以是我们所有客户和整个生态系统来此的地方。当然，现在他们已经超出了这个地方的容量，甚至不是所有的员工都能参加所有人手会议。

The logic for building it was that they had a movie theater that they used to do their monthly all hands meeting, and they wanted to have this opportunity to do it on their new campus too. It’s wild. When you look at it, you just can’t believe the scale of this building.
他们建造它的逻辑是，他们有一个电影院，用来做每月全体员工会议，他们希望也能在新园区里有这样的机会。这太疯狂了。当你看到这座建筑时，简直无法相信它的规模。

David: All right. I think now is the right time, while we’re talking about the campus and Epic culture, to really talk about Epic culture.
大卫：好的。我认为现在是时候，在讨论校园和 Epic 文化的时候，真正谈谈 Epic 文化了。

Ben: Yeah, because the first thing that you have to understand is Judy refers to it as a software factory. When you keep looking at it and you’re like, why is it so weird? The biggest takeaway is in Judy’s mind, since they don’t ever go buy any other companies and they don’t have any competencies at the company other than making software, what they are is a factory that churns out software. They take in software developers and they turn that into software for the medical industry.
Ben: 是的，因为你首先需要理解的是，朱迪将其称为软件工厂。当你不断审视它时，你会想，为什么它这么奇怪？最大的收获在于，在朱迪的思维中，由于他们从不收购其他公司，公司里除了软件开发之外没有任何其他专长，他们实际上是一个生产软件的工厂。他们接收软件开发人员，然后将这些开发人员转化为面向医疗行业的软件。

David: That’s funny. Apparently, she was just ahead of her time with…
大卫：真有趣。看来她只是比时代超前了一点……

Ben: The AI factories?  本：AI 工厂？

David: Was it NVIDIA and Dell calling? Yeah, AI factories now.
大卫：是英伟达和戴尔打来的吗？是的，现在有了 AI 工厂。

Ben: Absolutely. It starts to click and makes more sense when you think, well what would a factory for turning developers into medical code, medical applications look like? Well, Verona, Wisconsin.
当然了。当你想到，一个将开发者转化为医疗代码、医疗应用的工厂会是什么样子时，这就说得通了。威斯康星州的韦罗纳。

David: While we’re on culture here, one of the most amazing things about the campus is Epic has a list of 10 commandments. The Epic 10 commandments is like Moses in the Bible here. They have them posted in every bathroom and in every break room across the entire campus. It’s open to the public. You can just go in and see the 10 commandments other than the bathrooms there.
大卫：说到企业文化，校园里最令人 amazed 的事情之一是 Epic 列出了十条戒律。Epic 的十条戒律就像是圣经中的摩西十诫，它们被张贴在校园内每一个洗手间和休息室里。这些戒律对公众开放，你可以进去查看，除了洗手间之外。

The 10 commandments are number one, do not go public. Number two, do not acquire or be acquired.
十条诫命第一条，不要上市。第二条，不要收购或被收购。

Ben: By the way, those first two things, you don’t need to communicate that to employees. Only the CEO can do either of those things, so it’s just funny to put it as commandments. That shows how deeply Judy feels it needs to run in all the employees.
本：顺便说一下，前面那两件事不需要告诉员工。只有 CEO 能做这两件事，所以把这些当作戒律写下来真是有趣。这显示了朱迪认为这需要深入到所有员工中的程度。

David: And I think the other big motivation for doing this and having it there in the bathrooms, is every customer who comes to visit, it’s right there to the customers too. We will never go public, we will never be acquired, and we will never acquire another company. You can trust this is one system forever.
大卫：我认为在洗手间里放置这个系统还有一大动力，是因为每一位来访的客户都能看到它。我们永远不会上市，也不会被收购，也不会收购其他公司。你可以相信这是一个永久存在的系统。

Okay, so that’s one And two. Number three, software must work. Number four, reality equals expectations. Number five, keep commitments, even the unspoken ones. Number six, focus on competency. Do not tolerate mediocrity. Number seven, have standards, be fair to all. Number eight, have courage. What you put up with is what you stand for. Number nine, teach philosophy and culture. And number 10, be frugal. Do not take on debt for operations.
好的，那么一个是和两个。三点，软件必须好用。四点，现实等于期望。五点，即使是没有明说的承诺也要遵守。六点，专注于专业能力。不容忍平庸。七点，有标准，对所有人公平。八点，有勇气。你忍受的，就是你所代表的。九点，传授哲学和文化。十点，节俭。不要为了运营而负债。

Ben: Zero of those pertain to healthcare. When I was looking at them, I kept thinking, oh, I’m going to find something here about every life is important, or the patient is at the center of everything. No. This is how to run a company. This is my opinion on how to run a company, period.
本：这些都与医疗无关。当我查看这些内容时，我一直在想，我会找到关于“每个人的生命都很重要”或“患者是所有事情的中心”的内容。没有。这是一家公司的运营方式。这是我关于如何运营一家公司的观点，仅此而已。

David: And I think specifically to your point, this is a pretty good way to run a software factory.
David: 而且我认为就你的观点而言，这确实是一个很好的软件工厂运营方式。

Ben: So these hang in the bathroom. Other interesting things about the campus, they have wedding bells that will play campus-wide when a new client is signed. Just showing that that’s the type of commitment that this is. It’s a, we’ve now married this client for the rest of our lives.
本：所以这些挂在浴室里。关于校园的其他有趣事情，他们有婚礼铃铛，当签下新客户时，会全校播放。这 just 展示出这种承诺的性质。我们现在已经与这个客户结为终身伴侣。

David: It’s like the wedding march. That’s their version of ringing the gong.
大卫说：“就像婚礼进行曲。那是他们敲钟的方式。”

Ben: We haven’t really talked that much about what it is like to be an employee there, so this is probably a good time to do that. This is an insanely awesome training ground if you are a smart, ambitious person out of college.
Ben: 我们还没有太多讨论在那里做员工是什么感觉，所以现在可能是个好时机来谈谈。如果你是一个刚从大学毕业的聪明且有抱负的人，这里是一个超棒的训练场。

People accuse them of being cult-like. But there are ways in which that’s a good thing. They take you fresh out of your career and they teach you everything. When I say everything, I mean how to take notes.
人们指责他们像教派一样。但其中有一些是好事。他们会把你从职业生涯中拉出来，然后教你一切。当我提到一切时，我指的是如何做笔记。

There is an Epic way to take notes on a yellow legal pad. There is an Epic way to write emails. These are hardened practices over the years that they just believe through iteration, through testing, through data.
在黄色便签本上做笔记有 Epic 的方式。写邮件也有 Epic 的方式。这些是多年来通过不断迭代、测试和数据验证形成的固定做法。

David: Probably going all the way back to Neal, Meditech, and the three days in Boston.
David: 可能要追溯到 Neal、Meditech，以及波士顿的那三天。

Ben: This is the best way to do this, period. We’re just going to teach everybody the best way to do everything, and everybody is going to be reasonably robotic. We can trust that once we squeeze you through the Epic System, when you come out the other side, you are able to operate in a way that works really, really, really well in our machine, where people can really trust each other.
Ben: 这是唯一正确的方法。我们要教给大家所有事情的最佳做法，让每个人都变得相当机械化。我们可以信任，一旦你通过 Epic 系统，出来后就能以一种在我们的机器中运行得非常好且人们能够彼此信任的方式操作。

Because of that high level of trust, there are very few middle managers. You understand the system that everybody else works within, and you don’t have to corral chaos. Most of the people that are hiring are right out of school, so they’ve been there for a long time.
由于这种高度的信任，中间管理层非常少。你理解其他人工作的系统，并不需要控制混乱。大多数招聘的人都是刚从学校毕业的，所以他们在那里待了很长时间。

They don’t have budgets, which you can only do when you have a high trust environment like this. There are some financial controls of course, but Judy’s got this great story that she used to go see customers and they’d say, oh this is the right thing to do. I just don’t have the budget for it this year, so we’re going to push it next year. She’s like, that’s stupid.
他们没有预算，这只有在像这种高度信任的环境中才能做到。当然有一些财务控制，但朱迪有一个很棒的故事，她曾经去见客户，客户会说，这是正确的事情，我只是今年没有预算，所以我们明年再推。她会说，这太愚蠢了。

Or they would tell her, can we squeeze this in this year? Because if I don’t spend this money, I’m going to lose it in my budget. And she would say, well that’s also stupid, so at my company, we’re not going to have budgets like that.
或者他们会问她，我们今年能挤进这笔开支吗？因为如果不花这笔钱，我会在预算上亏本。而她会说，这也太愚蠢了，所以在我的公司，我们不会有这样的预算。

They’re super light on titles. You might have a business card, whether you’ve been there 20 years or 6 months, that says implementation, that you hand to a customer when you go and do an engagement. Everyone does immersion trips, where the software developers, everyone is required to spend time in clinical settings like operating rooms to directly observe workflows.
他们对头衔非常轻描淡写。你可能会有一张名片，无论你在那儿工作 20 年还是 6 个月，上面写着“实施”，当你去进行一项合作时会把这张名片递给客户。每个人都进行沉浸式旅行，软件开发人员必须花时间在临床环境中，比如手术室，直接观察工作流程。

David: I think when you start you have to do five of them, and then you do more every year.
大卫：我认为你开始时要做五个，然后每年再做更多的。

Ben: Wow. Y Combinator preaches, go talk to your customers, spend time with customers. Epic’s been doing this forever. This is the Epic way that (I think) the rest of the world woke up to and startups internalized as doctrine. But every person in the company, spending time in medical settings, talking to customers, hugely valuable.
Ben: 哇。Y Combinator 嘘传，去和你的客户交谈，花时间与客户在一起。Epic 很早就这样做。这就是 Epic 的方式，我想全世界其他地方后来才意识到，创业公司也内化为教义。但公司里的每个人，花时间在医疗环境中与客户交谈，非常有价值。

On the developer side, there’s a super prescriptive software methodology that they use to minimize bugs. You go through this intensive training for six months when you join, and then when you start programming, the whole system is designed to run minimizing the number of hours between when a line of code is written and then when it is tested, so if a bug is found, then you drop everything as the original developer and you fix it, so that you still have the whole context fresh in your head. You don’t go months, then the system gets tested, and bugs aren’t allowed to compound into bigger problems this way. They get caught right away.
在开发人员方面，他们使用一种非常规范的软件方法论来尽量减少错误。当你加入公司时，需要进行为期六个月的密集培训，然后当你开始编程时，整个系统的设计目的是尽量减少从编写代码到测试的时间间隔，如果发现错误，原始开发人员会立即放下手头的工作去修复它，这样还能保持整个上下文的新鲜感。不会等到几个月后再进行系统测试，这样错误不会累积成更大的问题。它们会立即被发现。

David: And I believe the rule is that every developer must fix their own bugs.
David: 而我认为规则是每个开发者必须自己修复自己的 bug。

Ben: That’s my understanding too. It’s this method of software engineering that places way more importance on a zero bug environment because lives are on the line than other ones. You’re not necessarily going to ship software the fastest way. You may not even ship the most innovative, clever, amazing cutting edge. You’re just going to make sure that you’re shipping bug-free software.
本：这也是我的理解。这种软件工程方法更注重无错误的环境，因为人的生命安全是关键。你不一定能最快地发布软件。你甚至可能不会发布最创新、最巧妙、最前沿的软件。你只是确保发布的软件是无错误的。

David: Well I think the reasons are twofold. One, it absolutely is right that lives are on the line. If an order for the amount of dose in a prescription gets messed up because of a bug, a lot of people are going to die.
大卫：我认为原因有两个方面。首先，生命确实取决于此。如果因为 bug 导致处方中的剂量数量出现错误，可能会有很多人因此丧生。

And also the complexity required for the revenue cycle and billing for your customers is of paramount importance. You cannot have bugs there either, or at best the hospital’s going to lose a lot of revenue opportunity. At worst, they’re going to get sued for federal crimes, for medical fraud.
并且，您客户在收入周期和账单方面所需的复杂性也至关重要。这里不能有错误，否则最好情况下医院会失去很多收入机会。最坏的情况下，他们可能会因联邦犯罪、医疗欺诈而被起诉。

Ben: Great point, so that means you need a…
Ben: 好点子，那么这就意味着你需要一个…

David: Highly robust system.
大卫: 非常 robust 的系统。

Ben: Yes. The work done as an implementation person at the company is insane. It’s like military-level logistics. You’re handling multiple customers, all of which are among the most complex systems on earth.
本: 是的。作为公司实施人员所做的工作是疯狂的。就像军事级别的物流。你要处理多个客户，所有这些都是地球上最复杂的系统。

Peter Drucker famously referred to hospitals as the most complex form of human organization that we have ever attempted to manage. You have to understand all these dependencies at the customer and the status of a dozen interrelated things on a daily basis. You really are in this high adrenaline, high stakes leadership role as a really young person.
彼得·德鲁克曾将医院形容为我们曾经尝试管理的最复杂的组织形式。你必须理解客户的所有这些依赖关系，以及每天十几个相关事物的状态。你真的处于一个高压力、高风险的领导角色，而且还是一个非常年轻的人。

You can work 10–12 hours a day, but a lot of them love it because you’re winning. You’re doing really big things right out of school, you’re doing it with other really bright people, so they really try to get high IQ, high EQ, often very sweet Midwestern kids to take these customer-facing roles.
你可以每天工作 10 到 12 小时，但很多人喜欢这样做，因为你们在赢。你们从学校出来就开始做非常重要的事情，而且是和其他非常聪明的人一起做，所以他们通常会试图吸引高智商、高情商，常常是非常温和的中西部孩子来担任面向客户的角色。

David: I think also because the flat organization, you’re also doing it alongside other senior people and learning from them directly. Like the story about Carl and Sumit—Sumit as a young programmer working on a project with Carl, the president who’s also a programmer leading the team—that happens.
大卫：我认为这也是因为扁平化的组织结构，你可以在其他资深人士旁边工作，并直接向他们学习。比如卡尔和苏密的故事——苏密是一名年轻的程序员，在卡尔这位也是程序员的总裁的带领下参与项目工作，这种情况经常发生。

Ben: If you’re an ambitious, career-focused person, there is nothing more fun than winning in a high stakes environment with other high performers as a team. That plus the whimsy encapsulates pretty well the Epic culture. The result of that is it becomes the number one thing in your life.
Ben：如果你是一个有抱负且注重职业发展的人，在一个高风险环境中与一群顶尖人才合作并取得胜利，这绝对是最有趣的。再加上这种随性，很好地概括了 Epic 的文化。结果就是，这成为了你生活中最重要的事情。

If you talk to a lot of these people who spent time there or still work there, you’re all in and you’re in the middle of nowhere. This is the other job the campus does. You’re not really getting exposed to other things you could leave and go. They make it very easy for your whole life to become epic.
如果你和很多在那里待过或者仍然在那里工作的人交谈，你会发现自己完全沉浸其中，仿佛置身于世外桃源。这就是校园的另一项工作。你并不会接触到其他可以让你选择离开的东西。他们让你的整个生活变得非常“Epic”。

David: You could drive to the big city of Madison. I know we keep making comparisons and it’s a direct one with the campus here too, but the company that this reminds me the most of is those early days of Microsoft. This is exactly what being at Microsoft in the 80s and 90s was like when we talked to people doing that research,
大卫：你可以开车去马德 ison 这个大城市。我知道我们一直在做比较，而且这里也和校园很直接相关，但让我想到的公司是微软的早期阶段。当我们和那些进行研究的人交谈时，这正是 80 年代和 90 年代在微软工作的感觉。

Ben: And I heard from some people, too, when I was researching for this, two or three times Palantir came up of these bright-eyed, bushy-tailed smart young people, where you’re deployed into these really intense environments, but you know your stuff, you’ve been through the training, you’ve been through the process, you’re armed with good tools, and you’re going to go make it happen.
本：我在研究这个的时候，也听人说起过，Palantir 几次出现，都是那些充满活力、知识渊博的年轻人，你们被部署到这些非常紧张的环境中，但你们知道自己的业务，经过了培训，拥有了好的工具，你们会去实现目标的。

The other side of this is it is up or out. They aggressively trim bottom whatever percent of performers and they work you really, really hard. With the vast amounts of new hires, they’re trying to figure out if you’re going to cut it. It’s more cost effective to replace you than keep you as dead weight. You have lots of attrition in the first few years, but you know that once someone’s been there for a while, they’re good. You can count on them.
另一面是，要么提升，要么出局。他们会积极淘汰最差的那部分表现者，并且让你非常非常努力地工作。随着大量新员工的加入，他们试图弄清楚你是否能留下来。与其保留一个负担，不如替换掉更划算。前几年的员工流失率很高，但你知道一旦有人在那里待了一段时间，他们就会变得很好。你可以依赖他们。

Their method of hiring is crazy, and this is more common now to give out programming tests as a part of the hiring process.
他们的招聘方法很疯狂，现在这在招聘过程中更加常见，即在招聘时发放编程测试。

David: Oh, this story is so good. Can I tell it?
大卫：这个故事真好。我可以讲吗？

Ben: Yes, please.  本：可以，你可以讲。

David: We mentioned that Judy’s son was a programmer at Microsoft, and that’s how she went to visit him, part of the inspiration for the campus. His involvement in the company actually predates him becoming a programmer at Microsoft or even an adult.
David：我们提到朱迪的儿子是微软的程序员，她就是通过去看望他才接触到微软的，这也是校园的一部分灵感来源。实际上，他参与公司的事情甚至在他成为微软程序员或甚至成为成年人之前就已经开始了。

In the late 80s, Judy was hiring software developers, and found that interviewing them just wasn’t that predictive of whether they were going to be great software developers or not. Meanwhile, her son (I think) was in seventh grade or something like that, and was doing these programming competitions around the state. She was talking to him. It was like, well you do these programming competitions and there are these tests, and then you’re winning some of them. That’s a pretty good judge of whether you’re a good programmer or not.
在 20 世纪 80 年代末，朱迪在招聘软件开发人员时发现，面试他们并不能很好地预测他们是否会成为优秀的软件开发人员。与此同时，她的儿子（我想）在七年级左右，正在参加州内的编程竞赛。她和儿子交谈时提到，这些竞赛有测试环节，而且你还能赢得一些比赛。这其实是一个相当好的判断你是否是优秀程序员的标准。

Ben: They’re reasonably predictive.
Ben: 它们具有一定的预测性。

David: Do you think you could write one of these types of tests for me? I can use it at Epic and test software developers as we’re hiring them, and see if they’re any good.

Ben: And for 18 years, listeners, that was how they tested to determine if someone should work at Epic. Many, many times—I don’t know if the number is close to 100% or some large percent of the time—they just don’t interview you. They believe that their tests are predictive enough that that’s it. You can get a job offer, you come visit campus and all that, but like you get a job offer after scoring high on this test.

And it’s not just that test. There are other tests. There’s a Rembrandt test. They’ve got a bunch of tests. It’s all systemized and cataloged, and everybody takes one on the way in.

David: For every role in the company, yeah.

Ben: The culinary team we heard takes not full software developer tests, but logic tests on the way in.

David: Amazing. But yeah, Judy’s teenage son wrote the first test that is now no longer being used. I think the answers have gotten out on the Internet, but for a long time was used. It’s a funny story, but this was in the 80s. This was way before Google was doing this stuff. This was really out there hiring practices at the time.

Ben: So we’ve talked a lot about the internal culture. The most important thing that we haven’t really dove into yet is how it touches the outside world. The Epic culture is completely customer-obsessed. And I mean that the way we talked about customers before.

There’s a great quote from Jeff Gautney, the Chief Information Officer for Rush University System for Health. He says, “You get what you pay for 100% of the time, despite Epic being ’not cheap.’” You see that echoed over and over and over again in these customer conversations as reliable. It worked. They didn’t over promise on something. It is fully integrated at this point. No one gets fired for buying Epic the same way it used to be true about IBM.

David: Customers are always number one, everything.

Ben: They vote. The way that they pick the next things to build is when all the customers come to campus for their annual conference, they ask for ideas and then they vote, and take customer input as a way for figuring out what are we going to do next.

David: There are basically only three roles at the company. There’s software developer, project manager who are the implementations managers doing the new active implementations for new customers, and then there are technical specialists who do ongoing customer support.

There’s not a sales or marketing department. There are eight or so “salespeople,” in the company who only react to inbound requests, and they all came from either project management or tech specialist. That’s the whole company.

The technical specialists are the biggest group in the company. Every single customer of the 607-whatever hospital system customers that Epic has, every single customer has their own technical specialist teams for every single product that they use. If you’re a hospital system, you have your own technical specialist team for your EpicCare, EMR, for MyChart, for Resolute, for Cosmos, for you name it, anything you use, you have your own dedicated team for that.

Then on top of that, every customer has their own dedicated BFF (best friend forever) who is a single person within Epic, and their sole job, their only job is to make sure that you as a customer are successful with their products.

This means they do things like they grade you as a customer every year, benchmarked relative to what other customers are doing and how you’re doing with the Epic tools. They will send separate report cards every year to your CEO, CIO, and CFO, and they will grade you one through five on a bunch of dimensions. Then they will show you benchmark data against other customers at your peer set of relatively similar sized hospital systems, how you’re doing.

Ben: Wow, that’s crazy.

David: I’ve never heard of any other company that does stuff like this.

Ben: Well, they have a lot of leverage in the customer relationship. I think at this point in history, 2025, when the customer wants to do something a certain way and Epic wants to do something a certain way, ultimately Epic is customer-focused, so they will do whatever the customer wants, but they’re going to lay out very compelling convincing arguments why their way is the correct way. What this leads to are things like a standard package.

A lot of times when people are setting up Cerner, every implementation looks completely different. Epic is highly opinionated. Please use as much standard stuff as you can so that we can easily push out updates, or we can easily add-in new modules for you, or interoperability all works exactly the way that we’re thinking it should.

They have a strong negotiating position with customers when they’re saying, ah, I think you should do it this way. Because at some point they may choose to just say, you know what? I don’t think you’re ready to be a customer yet. I think we’re going to focus elsewhere this year. We’re going to pick up only 10–20, maybe 30 new customers.

David: And we’re happy to wait.

Ben: We’re happy to wait until you’re ready to work with us. And they actually have the leverage to pull that off now.

David: To your point about the standard implementations, I believe this is the only way that you can get discounts on pricing with Epic, is by doing either fully or mostly standard. I think there probably are some tiers based on how standard your implementation is, and the more you deviate from it, the more you have to pay.

Ben: I could see that. I know if you stay up-to-date on things like database maintenance and versioning and all that, then they give you discounts.

David: So all of this sounds epic accruing power for Epic, which it is. There is also this almost altruistic part of the company and their customer relationships. And I think this comes from just Judy and who she is as a person.

Ben: Altruistic capitalism does feel like ultra competitive, ultra value maximizing. Altruistic capitalism is how I would describe the company.

David: I think that’s how you sum up Epic. This altruistic piece is despite certainly being expensive, they basically never raise prices once you’re a customer. They do, but their average yearly increase is about 2% across the board, so below inflation. Compare that to lots of other software companies out there. They’re not raising prices 2% every year. They also do things like they have never, in its entire history, changed the price of MyChart.

Ben: We got told this multiple times. I think that’s a red herring. We don’t know what the bottom line price looks like. We got told one piecemeal. It’s not like we have a full contract in hand of what it looks like to be a customer and add up all the sub components.

David: Good point.

Ben: Two points to make. Yes, they’re customer-obsessed. Yes, they’re listening. But yes, of course it’s to do what’s in Epic’s long-term interest. The core functionality of if you’re a customer, the reason you pick Epic is to turn an interaction with a patient into as many dollars as possible for the health system without risking downside.

David: With the lowest risk possible.

Ben: That is why the customer is picking them. What is Epic trying to do? Epic is trying to win deals, stay in forever, and achieve world domination. They do these very interesting things that feel very customer-focused, and are, but are also very valuable for Epic.

They’ll recommend alternative third party new pieces of software to their customers. Some new thing comes out, oh it’s 2020. Telehealth is suddenly really important. Here’s a HIPAA-compliant way to do Zoom. By the way, we’re going to start working on our own telehealth thing. It’ll be out soon. You should feel free to use Zoom right now. By the way, when our new module comes out, it’s just going to be free to you. You’re already a customer, it’s just going to be free to you.

You’re certainly not going to go around shopping for some new thing when you know that it’s just going to come for free to you, and you’re not going to take it right away because it’s going to be too bare bones, but at some point it’ll get good enough where you can say, oh yeah, I’ll just adopt the Epic version now, part of my enterprise-wide agreement. It’s this amazing bundling strategy that certainly reminds me of the Microsoft episode.

David: You’re totally right.

Ben: I think that’s the right way to look at it. They’re customer-obsessed because in the long-term, that is the right thing to do for Epic also. This is not a new realization.

There is a Jeff Bezos quote, and I just thought of it. I don’t have it in my notes, but it’s something about in the long run, there is no difference between what the customer wants and what Amazon wants. I distinctly remember him saying this in 1999 or something, some really old video.

Epic is absolutely customer-obsessed. Again, CEO, CIO of hospital systems because if you deliver for them, you deliver for Epic in the long run.

David: Well, that’s like—

Ben: That’s the goal of running a company.

David: Theoretical underpinning of capitalism, right?

Ben: Right.

David: All that to say, it is a very fascinating corporate culture and organization.

Ben: All right, so listeners, if you know anything about this industry, you know that we haven’t gotten to the important part yet. We’ve gotten to the Kaiser deal, that was a big deal, and got to moving to Verona.

It’s an important part to understand the culture, and it’s this cutesy thing that most journalists who write about the company latch onto, oh cool campus, like I should go take some pictures and write a cool story about campus.

There’s a whole big, crazy thing that happens as a part of the Great Recession and some legislation that gets passed, transformative for the industry and causes a whole bunch of good and a whole bunch of bad to happen.

But before we do that, this is a great time to thank good friend of the show ServiceNow. ServiceNow has been working on something really exciting. CRM. Now, I know we’ve talked about ServiceNow as the AI operating system for the enterprise, but what you might not know is they’ve also quietly been building a billion dollar-plus CRM business for years.

David: And part of the reason it’s been hiding in plain sight is because ServiceNow has always been one single platform for all your company’s data and operations. It’s a totally natural consequence that ServiceNow is also one of the best ways for the whole enterprise to access and interact with customer data.

Ben: It’s fascinating because ServiceNow approaches CRM from a completely different angle. Traditional CRM systems were built decades ago, primarily to record data and report on activities, not to take action or connect customer facing teams across your business. ServiceNow believes the new age of CRM is not just about selling, but also about delivering service across the whole totality of your organization.

David: Oh, you mean delivering service, now?

Ben: Hey yo.

David: But yes, exactly. Think about it. If you have separate systems for sales, service, and operations, you end up with what ServiceNow calls human middleware—employees manually updating different systems with the same information. But ServiceNow is all just one platform and one single source tree.

Ben: Ah, sounds like a familiar strategy.

David: Kind of like what we’ve been talking about this whole episode. Service or sales interactions automatically get updated everywhere on ServiceNow because it’s just one platform. So since ServiceNow is already your enterprise operating system, shouldn’t it also be your CRM?

Ben: And timing is everything with the rise of AI agents. Let’s say a customer contacts support about a delayed shipment. In traditional CRM, you might log the complaint, but the root cause remains hidden in your operation system. With ServiceNow’s modern CRM approach, AI agents can seamlessly access your data across departments from inventory to logistics, to consumer history, and not just track the issue but actually resolve it. It’s not just about managing customers, it’s about connecting your entire business to serve them better.

David: So if you want to learn more about ServiceNow’s modern approach to CRM, go to servicenow.com/acquired and just tell them that Ben and David sent you.

Ben: Okay, so we’re coming through the 2000s here. We just got through the Verona campus. You know everything about Epic’s culture now, or at least everything that we could discern from the outside anyway. And we’re in this pretty interesting era in 2006.

We’re in the Bush administration here in America, and Bush says in a state of the union, “For all Americans, we must confront the rising cost of care, strengthen the doctor patient relationship, and help people afford the insurance coverage they need. We’ll make wider use of electronic records and other health information technology to help control costs and reduce dangerous medical errors.” Wide applause.

David: This is one of the craziest things to me in doing the research. The narrative out there, and certainly in as much as I knew or paid attention to any of this, was that Obamacare and the Obama administration were the ones who really pushed EMR adoption and meaningful use and all this stuff that we’re really going to get into. Totally bipartisan, totally started in the Bush administration.

Ben: Just to give you a little look into how much the window changes of which side represents which party. The next paragraph, George W. Bush also says, “We will do more to make this coverage portable, so workers can switch jobs without having to worry about their health insurance.” It’s crazy. If you’re a Republican during the Obama era talking about having coverage that’s portable across employers, that’s a scary thing to be talking about just four years later.

David: So funny.

Ben: You’re starting to get these political wins of, hey, everyone wants a good system for electronic medical records. We think in the abstract there’ll be a lot of good that comes from it.

David: Well, I think there’s an even deeper motivation than that. In 2006 already, I think everybody knows in America the current healthcare system sucks. Yes, there are great things about it, but overall this is cost disease run rampant, huge portion of GDP, massively inefficient. We want to try and fix it.

Ben: How to fix it, we don’t all agree on.

David: How to fix it, we don’t know. But this promise of digitizing it and incentivizing EMR adoption is held forth as a promise that can deliver us from this problem. Right?

Ben: It feels like a step in the right direction.

David: At the time, only 13% of healthcare facilities in America had an EHR system at all. This is a massively not digitized industry here in the mid-2000s.

Ben: Which I think there’s some pushback on that 13%. People would say, well the definition of EHR just changed, so actually there were a lot more than 13% that had it, but that’s the best data that we have is that.

David: Fair enough.

Ben: Okay. Now before we get to the actual legislation and what happened, there’s one other concept to have in your mind, which is interoperability. This word comes up every time Epic comes up or any EHR comes up, and it’s worth knowing the buckets.

There’s the first and easiest interoperability, which is Epic to Epic at a different hospital. I want to transfer my records from one hospital to another. They also have Epic. It’s the same technology that should transfer easily.

Two is Epic to another EMR that’s at a different hospital. Epic to Cerner, Epic to Meditech, Epic to Allscripts, Epic to some home-rolled system. You can imagine the technical reasons why that would be harder.

David: They have different architectures. All the other ones arguably, except Meditech, don’t have a single database, et cetera.

Ben: And standards have not been quite as standard in this industry as they are in SaaS software. Easier B2B software mode.

Now, before we get to the third category, let’s just think about some of the incentives that are probably at play here. Epic transferring to themselves, fine, easy. A hospital transferring to a different hospital, you can imagine these places are competitors. They’re businesses. They may not want to support that unless it’s really in the patient’s interest, but they at least can be sensitive to it. Epic to another EMR at another hospital, well not only the hospitals maybe don’t want that. Maybe Epic doesn’t love that either.

David: Interests are aligned against this happening. Epic doesn’t want that, and the hospital doesn’t want that.

Ben: And they talk about a lot of good reasons why. Actually, we do want that. But let’s just call a spade a spade and say there’s no business reason why Epic would love for that to happen, other than of course it’s in the patient’s interest and everybody really should do what’s in the patient’s interest because we all get care from multiple places.

Then there’s this third category, Epic to third-party application that want to use data from Epic, or sit on top of Epic, or interoperate somehow with Epic. As a company, they have been very, very careful about this one over the years. And for good reason.

You don’t want patient data to leak. Epic has publicly referenced the fact that they have never had a Cambridge Analytica situation because they’re very, very careful about sharing data with other application developers. But the result of this is that it’s been much harder to integrate with Epic as an application developer than you would be used to in any other software category.

David: And again, very justifiable reasons why that should be the case—we’re dealing with HIPAA data here—but also massively in Epic’s interest for that to be the case.

Ben: It’s very convenient as a strategy. As for that first scenario (Epic to Epic), it’s actually awesome. They have this thing called Care Everywhere. Today, there are 20 million patient records exchanged daily. I used it as a part of prepping for this episode to join all my MyChart accounts across the three health systems I have in Seattle. It just seems to work pretty well.

There’s a great story of how it actually happened and how it came to be. Judy made the call personally that Care Everywhere wasn’t a thing or shouldn’t be a thing where their customers could pick and choose if you were enabling it. It worked across all Epic customers, even if they were your local competitor.

Here’s the story. One of the first customers to accept that new software that came with Care Everywhere, unknowingly agreed to the interoperability feature. He later admitted that he would’ve declined it if he realized that it was included in the contract that he was signing.

David: This is the CEO of that health system who later admitted that, yeah.

Ben: Of that hospital. And Judy described it as pure luck that Epic was actually able to move ahead. After that win, they then made it mandatory for all of their customers, and they retrofitted old versions of the software to support Care Everywhere so every Epic customer in the US has it and can share with every other Epic customer in the US.

This is their talking point of, hey actually we have lots of interoperability. We launched this thing called Care Everywhere. It shares millions and millions of records all the time.

David: They talk about, hey, we are the biggest sharer of medical record data of anybody.

Ben: So coming into 2008, that’s the historical baggage that you should know about in Epic land, of they believe they’re doing a lot of interoperability in the way that they like to do it. Almost no one is great at interoperability. I saw some transcripts of talking with hospital administrators who are interoperability in this industry is just laughable, period. No one’s incentivized to share with each other unless they absolutely have to. It’s not easy. These are incredibly complicated systems, and there are lots of risk.

David: One CIO put it to me in an interesting way when I was chatting about this with him. Because it’s patient data and health data, there’s this, we feel like interoperability should be a thing. You should be able to share your data everywhere, and sure, of course you should. I don’t want to discount that whatsoever.

However, he was like, imagine this was a different industry. Imagine we’re the airline industry. Does United share their customer data with Delta?

Ben: Even though it’s customer friendly to do so?

David: Even though it’s the customer’s data, no. Of course not. They never would. Do I feel great about sharing my patient’s data with my competitor down the street? No, of course not.

Ben: This is where you really start to feel the friction. I’m sure you’re listening to this and you’re emotionally getting charged up at this point because you’re feeling your inner capitalist think, well it’s a business. They should do the things that make sense for them as a business.

You’re feeling your inner human being who is part of a society that has your own health needs thinking, well maybe, but this thing shouldn’t be subject to the bad parts of capitalism. Maybe this thing should function differently. Business interests feel yucky to me, that business interests are governing the way that things get done. You should feel that tension because this is one of those bothies.

David: Well that describes the whole healthcare industry. Make no mistake. This is definitely a for-profit industry. It’s highly regulated and there are all these issues.

Ben: Okay, so we’re into the meat. 2008, the great financial crisis happens. At some point we should just do a whole episode on the great financial crisis, the collapse and the government bailouts, and how we managed to figure out how to not collapse as a nation and a global. We pulled out of it and it was amazing. Took some time, but we pulled out of it.

David: But one element of pulling out of it, just like during COVD, is the government said, all right, we need…

Ben: Stimulus, baby.

David: …stuff. We need stimulus. We need programs that we can throw money at the economy.

Ben: Interest rates go to zero, money out all over the place, turn on the printers, figure out how to get people doing productive stuff and reward them for it.

David: And there’s the monetary policy stuff of interest rates to zero. But there was also the fiscal policy stuff of we need to helicopter money into the economy.

Ben: So the question is, when you’re going to helicopter money into the economy, you could mail everyone checks. That happened during COVID.

David: Not an ideal way to do it.

Ben: A more productive thing to do that calls all the way back to the Civilian Conservation Corps in the FDR New Deal era is we want to look for shovel-ready projects. What are things that we just all agree on are good ideas for the country that should happen? And let’s just pass some legislation that rewards the crap out of people with free money for doing the things that we think are a good idea anyway.

The hope is you get this double whammy. You get the money distributed, which is just a goal. You’re just trying to create jobs, trying to create economic motion, and you get something accomplished that is widely agreed upon to be a good idea. Oh my gosh. A shovel-ready project right here, electronic medical records. Let’s do it. Let’s just figure out how to finally make that a thing.

So the goals: (1) fiscal stimulus to stimulate the economy after the great recession, (2) promote the adoption of electronic health records, (3) promote the use, which is different, the actual use…

David: The meaningful use.

Ben: …of electronic healthcare records. Not only do we want people to become users in your system that never log in. We want them logging in all the time using the stuff, and promote the adoption of interoperable standards so that providers could share patient data nationwide. These are the goals of the HITECH Act.

David: The 2009 Health Information Technology for Economic and Clinical Health Act.

Ben: I love how they name these things.

David: I know. Which gets folded into the almost trillion dollar American Recovery and Reinvestment Act.

Ben: The mechanics. In 2009 when the bill is passed, there is $27 billion available in direct incentive payments to hospitals that implemented electronic medical records. If you include broader incentives, other health IT projects, data exchanges, training, the total actually comes to $36 billion.

This is amazing. Imagine if you’re a software startup and the government just starts mailing checks to your customers, not only for signing up and becoming a customer and paying you money but then paying them even more for actually using your software, it’s the best thing that could happen if you’re a software vendor.

David: This is the government going to your customers and saying, hey, I’m going to give you money, but it’s a dedicated use credit card. The only thing you can use this money for and you must use this money for, is to buy this software startup’s products, and then you must also use them. If you don’t buy it and you don’t use it, not only are you not going to get the money, I’m going to penalize you and you’re going to have to pay me money.

Ben: Carrot and stick. Specifically, it amounted to $44,000–$64,000 per physician in incentive payments over a few years for adopting it. Now, that actually went to the hospital, but basically, you get paid for how many physicians are doing this.

David: Imagine a huge system like Kaiser with 11,000 physicians. It’s a lot of money.

Ben: HITECH contained the phrase ’meaningful use,’ which is this crazy phrase where if you say meaningful use or you even say MU to anyone, it is a triggering term in this industry.

First, meaningful use was a carrot and then as a stick, so after the stimulus ran out, David, as you were saying, after about five years, health systems would face meaningful financial penalties for not meaningfully using health IT software like EHRs.

There’s a KFF article entitled Death by A Thousand Clicks that has a quote on this. “The EHR vendor community, then a scrappy $2 billion industry, griped at the litany of requirements, but stood to gain so much from the government’s $36 billion injection, that it jumped in line,” as Rusty Frantz, CEO of EHR vendor, NextGen Healthcare put it—NextGen is one of the top 10 Epic competitors—“The industry was like, I’ve got this check dangling in front of me and I have to check these boxes to get there, so yeah, I’m going to do that.”

For everyone that wants to, just think this was the most amazing thing ever for Epic. Yes, it was obviously not very good. They had to do a bunch of hoop-jumping through to make sure that it was exactly the thing that the bill was going to reward. Everybody in this industry had to make sure that they spent a bunch of development time and a bunch of reprioritization in the company to make sure that it was exactly the thing that HITECH was saying that it needed to be.

David: It’s more nuanced than this is really good for Epic. Of course it was really good for Epic, but really it’s that this was really good for the entire EMR industry. The competitive dynamics within the industry are almost like a separate question.

Ben: Well, okay, so who’s it going to benefit the most? Probably the most reliable one. If I wasn’t going to do this before and now I just have a check dangling in front of me as a hospital to implement an EHR, I want the one with the integration that’s 100% going to work. I’m taking no risk.

Also, that Epic one? I think someone told me before that it was an expensive one. Well I guess it doesn’t matter that it’s expensive anymore because it’s free, so I’m just going to buy the good one.

David: It’s effectively free.

Ben: Epic, by being the high price, high value vendor, and the one that you could count on working with the lowest risk, were going to win in this situation.

David: That’s a great point. It’s like you’re getting a stimulus to buy a handbag, and you could get the Target one or you could get the Birkin bag, and they’re all free.

Ben: It’s not exactly like that, but it rounds to that. It also is interesting because it basically rewards the most reliable software, not necessarily the most innovative software. You end up not taking any risk in situations like this because you’re not going to get rewarded unless you actually stand the system up and then start getting meaningful use, so you end up with the one that’s just going to work.

What did HITECH actually do? We’ll go through each of the goals. Did it accelerate usage? Absolutely. Market penetration of electronic healthcare records went from 9% of hospitals in 2009 to 95% by 2014. It’s insane. David, what other markets have you ever heard of that saw usage go from almost nobody to almost everybody in five years?

David: Certain categories of software during the pandemic.

Ben: That’s a good point.

David: I would imagine maybe Zoom during the pandemic is the closest thing.

Ben: To be an Epic employee at this moment where suddenly your category is just free for all your potential customers, it’s crazy. Digitization was great for patients, even though a lot of doctors will complain about it. It is totally amazing to be able to message your doctor about something and pull up your own records electronically, as we talked about with MyChart.

David: Schedule your own appointments. You have all of the above. Manage your family’s care.

Ben: Absolutely. Okay, so then the next goal, cost reduction. There are stats both ways on if EHRs generally reduce costs. We found one stat that claimed that costs in hospitals went down by 10% with the introduction of EHRs. There are also arguments that the adoption of EHRs may actually have accelerated the ordering of unnecessary care as well as increased billing codes for either more codes or higher dollar codes for the same procedures.

That’s the counter argument to did it decrease costs in the system. The critics of EHRs say that basically more stuff is getting ordered from exam rooms for the exact same procedures than was happening before. Frankly, that’s the goal of hospitals buying an EHR. Part of it is revenue maximization.

David: Again, these are commercial entities. Even though many of them may be nonprofit organizations or part of a university system or what have you, at the end of the day, this is revenue being generated by a hospital, with a management team and with its primary staff being doctors and nurses who like to make money. The reason you go to medical school to be a doctor or a nurse is to get a good job and make a good living.

Ben: And the prestige of it and you want to help people, but it’s a high-paying job. There’s a great read called An Epic Dystopia. I will say this article presents a one-sided view of things.

David: This is The American Prospect article?

Ben: Yup. But there’s a quote. One doctor, for example, stated her supervisor regularly contacted her and said something like, “That appointment was a 2. Don’t you think it might be a 3?” Obviously in this case, a ’3’ could bill more to insurance than a ’2.’

Or someone else gave me a quote, “Hey, if you did X, almost certainly you did Y in that appointment. If you use those codes, you could charge more. And if you have a system, a computer system versus not having one, it’s more likely that you are billing for more stuff.” That would be the counter argument to this mass implementation of EHRs, saving costs for the system.

Data interoperability, not really. The legislation was prescriptive about meaningful use. It really wasn’t prescriptive about data standards that people talked about—that’s a goal of the legislation—but it’s not like there were incentives for data interoperability the way there were for meaningful use. So people follow incentives.

The data interoperability did not really happen, which was very convenient for Epic, who had a whole system that they made themselves and they didn’t really need to integrate with anyone to make the software suite useful. So again, as the leading player in the industry and the one that can do everything themselves, they didn’t need interoperability, and it wasn’t explicitly rewarded so customers didn’t prioritize it either.

David: And there is a fact pattern that opens Epic up certainly to criticism here, which is that Judy was on Obama’s health IT council through all of this, which was advising the Obama administration on the HITECH Act.

Ben: And other competitors had people on other committees too. It’s not like she was the only one with a voice in government.

David: I was going to say, that is a convenient fact that gets left out by a lot of people making that argument, or that all the competitors—Cerner, Allscripts, et cetera—were all on those councils too.

Ben: But let’s just look at the data interoperability thing. It didn’t happen, but it’s happening more now 15 years later. At least we have the foundation of digital records, so that as pushes and shoves happen, to make it more interoperable. Without operability, you can’t have interoperability.

David: And I think for me, that’s my takeaway of the HITECH Act and meaningful use here, at least when it comes to the industry of EHRs. Anytime you’ve got government coming in and distorting a market, you’re going to get weird stuff happening. Especially anytime you have government coming in and regulating how products are to be developed and used in a market, you’re going to get really messy stuff happening.

Ben: There were two really bad side effects here. One, by literally defining what is meaningful use, Congress not only accidentally designed the software and specified the features, but they also accidentally told doctors how they needed to do their jobs.

Doctors are running around now clicking nine things that they never needed to click before. Some of which are poor implementation by their hospital system, some of which is because the software is really complex, but a lot of it is just making sure that—

David: This is what the legislation requires.

Ben: Yes, complies with meaningful use so that the hospital then doesn’t come and get hit with a financial penalty.

David: This is the most unfortunate aspect of meaningful use, I think.

Ben: I think it’s the second most. I think the biggest one is they increase the regulatory burden of practicing medicine, period. Now since hospitals can face big financial penalties, there are all these mandatory fields and workflows everywhere forever, even after the stimulus runs out. It just generally increased the operational overhead of the whole industry.

The thing to optimize for now is hitting the MU definitions legally rather than the spirit, which is to help doctors and patients get more out of the system. You end up with things like health systems merging with other health systems because the cost of doing business is higher, which is a preexisting trend, but it’s certainly an accelerant. There’s more overhead, more burdensome regulation, just more crap in the system, more waste.

David: So all that unquestionably bad. At the same time, what’s the alternative? We’re going to be in the paper-based system? That’s not good. At least we have adoption here.

Ben: At least we have adoption here is what a lot of people have chalked this up to. It’s definitely better to be digital. Is this the best form of digitization that could have happened? No. Is digitization overall good? Yes.

David: And I think if you zoom way, way, way out, you give the most credit to the government and the legislators who created all of this. Was the goal actually a jobs program and an economic stimulus for the country? If that was the goal, A+. A lot of jobs got created because of this.

Ben: 18% of our GDPs worth of jobs are in this field, so it’s now a huge part of our society as people who work in medicine, for better or for worse.

David: And related fields to medicine like IT administrators, Epic administrators at hospitals. These are a lot of jobs and these are a lot of good jobs. And play it one step forward, these are all domestic American jobs, not dependent on imports, not dependent on manufacturing, that have created viable great career paths for a lot of people in this country. From a policy standpoint, maybe not bad.

Ben: Nah. I hate it, David.

David: Oh, I’m not saying I love the idea of jobs programs. I’m just saying if you zoom way out of what was the goal of the government in doing this? Did they succeed? If that was the goal, they succeeded.

Ben: It was good to create fiscal stimulus for that period of time where we really needed it. Should the government be in the business on a durable basis of using taxpayer funds to prop up industries and create and maintain a bunch of jobs in those industries? No, absolutely not.

It’s a very low bar for what you’re saying. Did it stimulate the economy? Mailing checks would’ve stimulated the economy. I look at this as, yes, it stimulated the economy and it had the free stapled coupon of we got some amount of electronic medical records, even though they’re not interoperable and even it’s not the best system we possibly could hope for as a country. It’s a better one than we would’ve had otherwise, and it came for free with the stimulus checks.

David: So back to the Epic story here.

Ben: What did meaningful use do for them? Well, interestingly, if you just take a step back and say, what is the byproduct of the government paying off a whole industry to adopt something new? What you’re basically doing is pulling forward the future and saying, this was all going to happen eventually. We want to make it all happen right now.

David: To be clear, I think especially after the Kaiser win, Epic was going to become the dominant player anyway, absent of meaningful use. They were starting to run the table on competition.

Ben: That’s the question, they were starting to. But what you definitely do when you throw $36 billion at the problem is you say, we’re going to close the door on anyone that might become a dominant player after this. The current competitive set is now what we’re dealing with, and we think the current competitive set is good enough that this is shovel-ready enough that we want the best ones to get implemented everywhere. These are stuck in there for multiple decades.

David: The switching cost here is enormous.

Ben: That’s a fair trade-off. I don’t even think it was that intentional of a trade-off that they made by passing this legislation, but it is definitely true that a new EHR that may have been more theoretically innovative in some way that could have come after HITECH wasn’t going to happen, at least for a long time.

David: Because you pulled forward so many RFP processes to a single point in time. The majority of them chose Epic, which they probably would’ve anyway, but a lot of those processes would’ve happened in the future, at which point in time other competitors may have emerged.

Ben: There’s no greenfield bidding for those theoretical, future innovative competitors that everyone’s bidding against your current system.

David: I buy that.

Ben: But that’s nitpicky. It’s a little bit like, for whom are we holding the door open? If you’re looking for a smoking gun on regulatory capture, I think the right way to characterize this is as regulatory tailwind rather than regulatory capture. I don’t think the folks at Epic loved it either. My impression is they felt like they were going to take this market and now they had to do it in this Frankenstein style way.

David: It definitely made the product worse.

Ben: It made the product worse. It increased burdens for everyone. It made it more sure that they were going to win the market because if something’s going to happen five years from now where it could happen now, you’d rather it happen now and it be certain.

David: But they certainly don’t love it that doctors have to check 57 boxes on every patient visit.

Ben: All this compliance burden and the software being frankly hard to use once it’s…

David: Legislated?

Ben: Yeah.

David: Product development by legislation, which to be clear isn’t just Epic. It’s all of them.

Ben: And also, just the complexity of software of this magnitude with this many different screens and participants and all that. A big criticism is that it takes time away from patients.

There was a 2016 study that showed that entering data into eh r consumes about two hours of doctor time for every one hour spent providing hands-on patient care. There’s all this other research around doctors now work 11–12 hours a day. They’re constantly responding to messages, which again is a hospital configuration thing. There’s a way to triage messages.

David: Another downside to the HITECH Act and meaningful use is that before digitization and moving all this activity from hospitals into the EHR, there were a lot of regulations and guidelines that maybe weren’t always followed, and that was for the best in the hospital.

Things like, it’s supposed to be doctors themselves who put in orders for pharmacy, for meds, or for scans or stuff like that. But in the old world, before everything moved into the EHR, doctors were supposed to do it, but they would have their medical assistants do it. If you’re seeing 20 patients a day and a whole bunch of them need scans or meds or whatever, you can just be like, hey, medical assistant, do all this, and they can do it during the day.

Ben: I’ll sign them all later.

David: Exactly. But now, once everything’s digitized and in the EHR, that means that the rules have to be followed because they’re tracked. That means that all of a sudden doctors don’t have as much help in slack in the system as they used to.

Ben: It’s interesting. This is the thing that ends up contributing to doctor burnout. But you do have to compare it to how it used to be. There was a great old study from 1970 that found that communications activities such as managing physical records accounted for 35%–39% of total hospital operating costs. That’s not the doctor’s time, but especially in the paper world, it was always a huge amount of cost and time from the hospital.

David: You’re shifting around the burden of this a little bit and creating more burden through all the meaningful use regulations. But this is not a new problem.

Ben: You know who else doesn’t love it? In 2017, Obama himself told Vox that he felt that the HITECH legislation did not live up to what he wanted. Here’s his quote: “The fact that there are still just mountains of paperwork, and the doctors still have to input stuff, and the nurses are spending all their time on this administrative work, we put a big slug of money into trying to encourage everyone to digitize, to catch up with the rest of the world, and that’s been harder than we expected.”

The quote, I actually don’t think it was at all about catching up with the rest of the world on digitization. I think we were a leader there. But if the hope was that we could somehow downgrade our costs to be in line with the rest of the world, that would’ve been great, and that did not happen.

David: One of the CIOs I talked to had a great quote on this. He said that, “Meaningful use in the HITECH Act wildly succeeded at digitization of the industry. It did absolutely nothing on the digital transformation of the industry. We digitized, but we didn’t transform in the way that I think people were optimistically hoping for.”

Ben: That’s interesting. The good news is that it can still come now that all the records are digital.

David: Now that we’ve digitized, yes.

Ben: You actually can do interesting things with the data that you couldn’t have done before.

David: And we’ll talk about when we get to the end of the story in a couple of minutes. The promise, at least right now, of AI and ambient AI in making a lot of this onerous process just disappear for humans.

On the back of all of this, Epic continues to win epically. In 2011, they hit a billion dollars in revenue. They keep winning all the big systems that come up for RFP. Johns Hopkins, Cedar-Sinai, UCSF, list goes on and on and on.

For Epic’s competitors, they had always been merging and consolidation had always been happening. But now with meaningful use being in place, consolidation really picks up. Which again, all of which is just going to accrue to Epic’s advantage because consolidation in this space means the products get more complex, they don’t work as well altogether as a suite, and Epic’s advantage just becomes all the more pronounced.

So 2008 Allscripts merges with Misys. 2010, that new Allscripts entity then merges again with Eclipsys. They keep on acquiring smaller players. Today, that company is called Veradigm. 2011 Meditech acquires LSS Data Systems. And then in August, 2014, one of the big ones that we’ve already alluded to happens. Cerner buys Siemens Health for $1.3 billion.

Ben: That starts the downward spiral for Cerner. That’s my understanding.

David: I heard in the research that even today in 2025, customers will still refer to themselves as either Siemens customers or Cerner customers. It’s still not fully integrated.

Ben: Meanwhile, I think post-Oracle acquisition, Oracle’s trying to rewrite it all anyway.

David: And that’s not going well, which we’ll come to later. This leads us right into the Department of Defense contract.

Ben: The motherload of all opportunities if you are an EMR.

David: VA contract, oh boy. The motherload of all opportunities. Or if you are an American taxpayer, the motherload of everything that is wrong with governmental waste in America.

But before we get into that story, we have some happier and better news to tell you, and that is to thank longtime friends of the show, Crusoe.

Ben: Thank you Crusoe for giving us a moment of levity here, and a moment of excitement and optimism looking to the future. Crusoe is not just an AI cloud platform. They are actually re-imagining how AI infrastructure gets physically built from the ground-up.

David: In the past we’ve talked about Crusoe’s climate-aligned approach, powering their GPU data centers with stranded energy. But what’s truly unique about Crusoe is that they’re a fully vertically-integrated AI infrastructure business. Crusoe’s founders, Chase and Culley, realized early on that in order to become the best AI cloud platform, you actually need to build the entire stack from sourcing the energy to building the data centers, and ultimately providing the end AI cloud service layer.

Ben: The best example of this is the giant 1.2 gigawatt AI data center that they are building in Abilene, Texas. They broke ground in just June of 2024 on an empty field, and now within a year they are about to turn on the first few buildings. Bringing on new capacity of this size in less than a year is crazy fast for the industry.

David: And to put that 1.2 gigawatts in perspective, if you take the entire data center capacity located in Northern Virginia today where 70% of the world’s internet traffic flows through, all of that is only 4.5 gigawatts. Crusoe’s single AI factory in Abilene will be more than a quarter the size of what powers a huge portion of the Internet today. And that’s just one of their locations.

Ben: Crusoe handles all of the incredible complexity of building physical AI capacity, so that their customers can just focus on innovation, not infrastructure. They just announced two new services to do that. Their managed inference service frees developers from managing servers, and their auto clusters service eliminates the operational burden of model training.

David: When you’re thinking about where to run your AI workloads, make sure you consider Crusoe. Because they operate and innovate at every single layer of the physical stack, Crusoe delivers unmatched price to performance, speed to market, and a platform that customers can rely on for years to come. It’s an incredible company, and Ben and I are excited to be investors in their recent funding round alongside NVIDIA, Founders Fund, and a whole slate of other great investors too.

Ben: That we are. To learn more, head on over to crusoe.ai/acquired. or click the link in the show notes. When you get in touch, just tell them that Ben and David sent you.

Okay, David, the DoD debacle.

David: The 2015 DoD debacle. The Department of Defense decides that they’re going to bid out a global EHR contract for all of their hospitals and healthcare across all branches of the military. Now, this is (at the beginning) just active duty US military, so separate from the VA system which comes later, the Veterans Administration, all the veterans of the US military.

This deal in 2015 is up until this moment in time, the biggest healthcare IT contract of all time. It ends up being a $4.3 billion deal, so even bigger than the Kaiser deal. It remains the biggest until two years later when the VA contract does go out. That is a $10 billion deal. Now, Epic of course bids on both of these contracts, and as you would expect, just like with Kaiser, it comes down to Epic and Cerner.

Ben: But not directly, because just to add to the insanity of this system, it’s basically impossible unless you bid on government contracts all the time to bid on a government contract directly. You need to pony up with one of the companies that subcontract off of someone who makes their bread and butter all the time by contracting with the US government.

David: They each choose their partners. There are all sorts of drama around this. Basically the knives come out on all sides, as we shall see with Cerner. If you win one or both of these contracts, this will keep your company going for years and years and years.

Drama aside, Cerner ends up winning both of these contracts, the DOD and the VA. Sadly, in what will perhaps not shock you at all, both of these projects, despite being huge at the bidding phase, go massively over time and budget. It’s really, really bad. The DoD system, the active duty system, only just fully went live late last year in 2024. This contract got bid out in 2015, so that is a nine year implementation process. The VA system is way worse. It is nowhere near fully live today.

Ben: And Cerner won both of these?

David: Cerner won both of these as a subcontractor won both of these. The VA system was bid out in 2017. The latest announcement from the VA about this project is that it will be live at all VA sites by, this is a direct quote: “As early as 2031.”

Ben: What?

David: Even the most optimistic scenario that they’re saying, which seems very unlikely, is this is a 14 year project.

Ben: The latest I have seen is that it’s still not live. They actually gave an ’as early as 2031.’

David: Now it is live at a few sites. It’s not like nothing has happened over the last decade. But oh my God, if as an American citizen or watcher of America, you were disgusted by the whole meaningful use thing, if you are an American taxpayer, this is just beyond disgusting.

Ben: So why? What took so long? Or what made it so expensive?

David: I don’t really know. I think it’s a combination of a lot of things.

Ben: Or I guess what are the incentives?

David: Well, it’s really unfortunate, but there’s an old saying that you make more money on failed government contracts than successful ones. I think that’s probably the incentives that are applying here.

Ben: Oh because as long as the contract doesn’t end and you’re still implementing, you can still keep finding more costs.

David: You can still keep getting paid. Now, I think it would be unfair to blame Cerner for this. Maybe some of the blame lives on them, but they’re a subcontractor to big government primes that are the GC here.

We talked about this on the Lockheed episode. This is just how the military industrial complex works now. You’ve got the compounding layers of bureaucracy of the government, the military EMRs generally as we’ve talked about. This is just a rat’s nest of awfulness of bureaucracy. You’ve got these multi-decade now projects with many billions of taxpayer dollars going into this. Still not live. Just freaking brutal.

Ben: Do you think Epic is glad they didn’t win?

David: Well, here’s the thing. Epic of course was part of this process bid on the RFPs, and I’m sure would’ve loved to have won them.

Ben: Because even the $10 billion initial price tag before the overruns is twice Epic’s revenue today, this transformative for your business in the best case.

David: Yes, kind of like Kaiser was transformative for Epic back in the day. That’s it. Talking to Epic customers, CIOs, and the research, they are down on their hands and knees, thankful that Epic did not win this deal.

Ben: Because Cerner just got dragged so into the process.

David: So into the muck here. And there were a lot of other compounding factors happening here. Cerner, we’ve talked about, already was now post Siemens, would you say 36 companies that had been acquired, get pulled together to make Cerner. Neal Patterson, the founder, CIO, and longtime leader right around this time, he gets cancer and then he passes away in 2017, so your founder and your leader is passing away in the midst of this very complex process.

After that, Cerner cycles through a whole bunch of different leaders over the next few years. Meanwhile, Epic is unburdened by this DoD and VA shitshow (for lack of a better word), and they just keep winning deal after deal in the large system providers.

Ben: And in their own way. This is a testament to how Judy thinks a company should be run. We’re going to stay extremely focused. We have a very particular playbook. We listen to customers. We meet our promises.

David: We’re hardcore about our software engineering and our product architecture.

Ben: When our customers find new use cases, we develop that software too. She runs a company in an unconventional way, and that unconventional way is proving to be the right way to win this market.

David: After the DoD deal, Epic wins Partners Healthcare in Boston, which is the new entity of Harvard and Mass General (MGH), and the original big research institution. They win all of the Mayo Clinic, all of their hospitals. That’s one of the biggest contracts. Again, outside the DoD craziness. They win Cambridge in the UK. They win Intermountain Health. Recently, they win CommonSpirit Health. The list goes on and on and on.

2018 Epic hits $2.7 billion in revenue. They announced that they have all 20 of the top academic hospitals in the US News and World Report rankings, which is critical for them because winning the top academic hospitals means that all the new doctors and nurses that are coming through getting minted by these institutions and trained, are all trained on Epic.

Ben: I think they sell them a separate educational license too. I think they treat the university hospital and the academic classroom as separate. I’m sure it helps to be in the hospital, but I think you also buy it as a school.

David: I’m sure that’s right. But also a huge part of medical education is practicing in the hospital.

Ben: And I think now 90% of med school students train on Epic.

David: That is the current statistic. 2019 Epic hits $3.2 billion in revenue. Then finally December, 2021, as we’ve been alluding to, Cerner gets bought by Oracle for $28 billion.

Cerner, as we talked about, was and still is a big company. They’ve acquired all these companies over the years. There’s a lot of revenue there. They’re big international and they have the DoD and VA contracts ongoing, which is a lot of money coming in. They’re doing maybe call it $5.5 billion a year in revenue, maybe a little more. But that’s been flat to declining since 2018.

Oracle again acquired them in 2021. Oracle now no longer reports Cerner’s financials as a separate segment within the company. They talk about Cerner and Oracle Health being a “headwind” to overall growth and profitability for the company. There’ve been a lot of layoffs within Oracle Health.

Maybe it’s too early to tell, but I think this is probably one of Oracle’s worst acquisitions of all time. You’d be hard pressed to find an analyst who would say that this was a great acquisition by Oracle, shall we say?

Ben: Yes, to put it lightly.

David: Meanwhile, this is all just great for Epic and totally reinforces Judy’s whole thesis of company building in this space, and her whole story to customers of one single integrated platform that is hardcore about software development, that is 100% customer-focused, that will never acquire another company, never go public, never get acquired. You can see why it’s just this warm hug embrace to their customers out there.

Ben: It becomes more and more different than everyone else in the market the longer time goes on. And the lesson here, which is really interesting, is they started slow, They started really slow.

They did things in a way where they almost built up momentum for the future, in a way that would pay off 20–30 years down the road rather than inorganically trying to take shortcuts and pull the future too far forward into today.

The first 20 years looks like an unimpressive company because they were just building strength, building muscle, growing the way that you need to grow in order to be as bulletproof as they are today.

David: That’s such a good point. I was trying to square in my mind earlier when we were telling the meaningful use story, how on the one hand it really was obviously good for Epic, an accelerant, and it further cemented the market dynamics where they were already emerging as the leader. On the other hand, when you talk to people within Epic, they’re very mixed on meaningful use.

Ben: I could never figure out if that was lip service of, oh, it didn’t help us that much. But when you look at the graphs of customer accounts and of revenue, it was going great.

David: It did pull forward some growth, but the trend lines, we’re going to get here anyway.

Ben: It’s not like it was some big massive step function in two years. That is not how the graphs look.

David: As we told the story, they had the better product, they had the better customer offering, they were on the way to winning anyway. I think to your point here about they’ve always been just philosophically allergic to artificial growth. I wonder if that’s part of why, to the extent they are serious about really being ambivalent about meaningful use, that’s the reason why.

Ben: They want to win slowly.

David: They absolutely want to win.

Ben: And they’re going to win. But they want to do it slowly because it will help them win harder in the long run if they win slowly.

David: Meanwhile for them, I think things have never looked brighter, basically. There are some risks that we’ll talk about, but they’re now starting to sell international and build that as a real market. It’s not huge, but it’s (call it) 10%–15% of the business now. 2023 they went live at London’s Guy’s and St. Thomas’ NHS Trust, which was (I think) their biggest ever single implementation and happening in the UK. The UK is becoming a real market for them.

Ben: Interesting. There’s another big tailwind that’s happening for them. You’ve probably been hearing from me over the course of this whole episode. There are tailwinds that don’t make you feel good, but they’re still tailwinds for Epic’s business. The acceleration of the trend where hospital systems are merging and rolling up all the smaller local practices.

David: Oh, totally. It’s just an excuse to rebid.

Ben: There are a bunch of reasons this is happening, but one of them is the Affordable Care Act. That also increased the compliance burden of practicing medicine, which was already really heavy from all the regulations over the years, including HITECH adding big penalties for HIPAA, for violating HIPAA.

That’s another thing we didn’t talk about in HITECH. That was one of the things that came stapled onto it, was even more strict oversight on HIPAA. You now require scale as a local medical practitioner, to be able to afford the compliance burden.

What that means if you play it out is all healthcare or most healthcare gets provided by these mega giant hospital systems rather than community clinics, which really benefits Epic, because their strategy from 30 years ago of going over the biggest and most complex health systems now looks totally genius because Those are the only customers really left standing.

I actually think this is one of the most messed up things in the US healthcare system. Aside from the really big hard to negotiate with private health insurers who have gotten a lot of power over the ecosystem, you now have also really big local pseudo monopoly hospital systems. This consolidation is not good. This consolidation will not lead to prices coming down, let’s just put it that way.

David: But you see why it’s been happening. You and I entered doing this episode expecting to be like, ah, the hospitals are really the bad guys. They’re charging so much money.

Ben: I don’t think the hospitals make very much money.

David: They don’t make much money at all. They’re barely surviving, which is why they’re merging.

Ben: Any money that the very successful ones are making, they tend to plow back into growth. Like we’ve been talking about, hospitals need scale in this day and age. It’s new buildings, it’s acquiring other practices locally. Everyone is just chasing scale because they constantly are having to do business with other scale players, so they need to size up to do that.

David: That brings us to the other big (I think) potential growth vector for Epic going forward that they’re absolutely pursuing. They have enough scale on the provider side now that they can start going to the other big players in the system, the payers, then also the biotech and pharma side, and (say) we actually have ways that we can work with you guys now and offer compelling products to you.

They call this the system of connectedness or the “grid of care” that you might sometimes hear from Epic. This is building products for and working with payers, the insurers, pharma companies, and other stuff like home health companies or post-acute rehab, et cetera. But really the big opportunities are payers and pharma.

One example of this is prior authorizations. Prior authorizations are a huge problem in the American healthcare system. This is when a doctor thinks that a patient needs either a medicine or a procedure, that the payer, the insurance company says, well you can’t just go do that.

Ben: It’s expensive enough that you need to ask us first on a case by case basis if we’ll cover it for this person.

David: Exactly. We need to prior authorize this. Epic now has enough data and enough scale on the hospital side that they can go to the payers and say, hey, prior auth, our customers don’t like it. You don’t like it. We have all the data. We can just automate this for you.

Ben: I would argue this is an area where you are seeing one of Epic’s favorite business strategies. We sell the main thing to a hospital system. We see what other vendors they’re using. We figure out if they should also buy that from us if we have some competitive advantage other than just a single vendor to be able to do it. Sometimes just being a single vendor with the same offering is enough. But then they try to figure out if they can also do that and include it in their enterprise agreement.

They want to sell everything to the hospital and be the single IT vendor. The hospitals do still buy other IT services. So the Epic playbook is to go from selling a hospital one thing to figure out how to then sell the hospital everything. Then once you’ve exhausted that, then figure out who else you can sell stuff to. That’s why they’re looking into payers and pharma companies. It’s how we can leverage the asset that we have to then now that we saturated this market, sell to other customers too.

David: Fair point.

Ben: All right, so that basically brings us to today. If you’re in this ecosystem, you’re going to say there are 50 things that Epic does that you didn’t talk about. That is true. There’s no chance that we could talk about all of that in this episode.

But there is one really cool, interesting thing that they are doing right now that we do want to talk about as we catch up to today. Then we’ll give you the stats on the business today, and we’ll talk about the future and then we’ll do our analysis. They launched something a few years ago called Cosmos.

David: This is pretty cool.

Ben: This is awesome. They’ve realized, okay, there is data on patients that is owned by patients and hospitals, not by us. That lives on a bunch of different servers. Some are on-prem at hospitals, some are in our cloud, some are on AWS, some are on Azure. But either way, there’s all this interesting structured patient data stored in EpicCare instances.

Can we anonymize that and get it all in an Epic-hosted instance of something very queryable and very useful for a bunch of activities? They did it. It’s called Cosmos. Cosmos has 295 million patients worth of data in it, all anonymized.

David: I think that across those 295 million patients, there’s data from 15 billion individual patient encounters. So structured data from a doctor encounter 15 billion times with patients.

Ben: It’s crazy. We were asking the question earlier, do EMRs or EHRs really benefit patients? There are some arguments that aside from how awesome it is to just access your records at home, there are a bunch of stats around, yes, it benefits patients.

It’s patient safety, it’s patient ease. There are studies that say 45% of patients reported improved quality of care with EHRs while only 6% notice decline. Epic has a stat in 2023, its system prevented 66 million potential adverse drug interactions and 250,000 potential surgical errors.

All of this seems very plausible. If you’re tracking all this stuff digitally, you can do intelligent things that improve care. But on top of that, more interestingly, what if all of the data was actually in one place and you could do stuff with it? What is the value of having something digital versus paper?

David: This is the utopian dream that people have always had, that the Bush and Obama administration had. Epic is finally doing it.

Ben: One very clear, interesting illustrative example is to imagine there’s something wrong in the water supply, but all the records are on paper. Unless you’re going and pulling individual files and then looking at some specific test result across a whole bunch of people, which you probably need a research grant to do, to actually go and sit down and pull all these individual files, you’re not going to find it.

But if you have a whole database full of information and you can quickly and easily look horizontally across a whole bunch of records, this is Flint, Michigan. This is how they figured out there was a water problem in Flint, Michigan, and you would not have found it in a paper-based world. Cosmos is that on steroids. What can you figure out about the whole world if you have 295 million patients’ worth of data in an anonymized, accessible database, and it’s accessible to any institution for free that contributes data in.

So all the Epic customers, anyone who opts in, gets access, inquires about it for research, or cool stuff like I have a really unique patient who has some crazy condition I’ve never heard of. Has this ever happened to anyone else in the world? And what was the result?

David: This is what’s really cool. They’ve productized this and made it free, so that any of their customers can just turn it on. Ben, exactly like you’re talking about, I’m a doctor, I have a patient, there’s something going on. Cosmos can surface to me, hey, here are other examples of similar cases, anonymized.

Ben: They call them lookalikes, I think?

David: Yeah, lookalike patients throughout the history of everybody that’s ever been on Epic. Here are the doctors who treated those patients, so this has already happening quite a bit (I think) with rare diseases and crazy cases.

Ben: I think so too. It’ll be useful for clinical trials. It’ll be useful for research. I do think it’s free right now, which is pretty interesting. We’ll have to see how they price and package it in the coming years. But yeah, you’re right. This is like the utopian dream of, wouldn’t it be cool if we had all this data in one place?

David: And then that really presage is something we’re going to talk a lot about in analysis, which is, wow, imagine what you can do with AI with this data. But we will get to that in a minute.

Ben: All right, so the business today, let’s just make sure we’re all on the same page on where things stand. They have 607 customers with 3200 hospitals in between them. As you know, they’ve never lost a single one, which is insane. They add 10 to 25 new health systems as customers each year. Their customers represent 590,000 physicians and 495,000 staffed beds.

David: And that’s across 325 million patients?

Ben: Worldwide. Yup, 280 million of which are in the US.

David: So basically almost all of America gets seen in some part of their healthcare by an Epic system.

Ben: That is correct. In revenue, last year in 2024, they did $5.7 billion, which grew 13% year over year over the last 5 years, and 16% last year from $4.9 billion to $5.7 billion.

David, I wanted to bring something up with you. They actually do less revenue than I would’ve figured. For people that are like, $5.7 billion is a lot. What are you talking about? If you divide it by their number of customers, it comes out around $10 million a year a customer.

If you live in the enterprise software world, that’s not crazy. This is the central nervous system of these giant health systems. This is what everything else relies on. They run their entire business on this. It costs a lot of money because there are all these people administering it.

I talked to someone at a mid-sized health system that said there are 100 full-time employees administering Epic at her hospital system. But Epic actually only captures about $10 million a year of the value created, so there’s this interesting dichotomy of, yes, it’s a lot of spend, but the minority of it actually goes to Epic.

David: It is this element of, I know I said altruistic earlier when talking about the company. You’re right, it’s not altruistic. But I think it’s really, really important to understand. It's a very long-term orientation. They could charge their customers a lot more money. They definitely could.

Ben: They didn’t used to be able to. I think they used to saturate willingness to pay. Now that they’re this dominant, they probably could. There are so many costs that get paid out to the consultants, the Accenture, Deloitte, IBM, Nordic, the post implementation people, the optimization people, the headcount internally, the lost revenue from doing the switch and taking that downtime. This costs health systems a lot. Epic actually just doesn’t capture that much of it.

I’m not as convinced that they have room to take price as much as I’m surprised they don’t capture more of the overall value of a central nervous system for a hospital system. They could probably capture some more, and as we get further and further in the future and they get more and more dominant, they certainly will gain more pricing power.

David: I think they could. Again, to your point of on average, $10 million a year cost for a piece of software that is so absolutely vital to your business, I think they could capture more. And I think part of the reason they don’t is they never want to give a customer any incentive to rebid or consider another solution. It’s like the Jeff Bezos quote about AWS in the early days, that he wanted to be an irrational and irresponsible decision not to use AWS.

Ben: Oh, to pick someone else, yeah.

David: I think they want it to be an irrational and irresponsible decision for a healthcare system not to use Epic.

Ben: I think that’s right. Just one other number to throw out to analyze this on a different vector. When I said $5.7 billion top line isn’t that big of a number in healthcare, United Healthcare, which owns an insurance company and a hospital system, does $400 billion a year in revenue. That’s wildly apples to oranges because they’re actually administering care in the case of their hospital system, so it’s a different thing.

But that company does $35 billion in EBITDA. United Healthcare’s profit dollars are six times Epic’s entire revenues. Epic has become this incredibly important and powerful linchpin in the system, despite not actually having that big of a profit pool in the industry. Or even maybe better put, of having that big of a revenue pool in the industry.

I came into this episode expecting to be like, my God, this company just mints money, and for how much people talk about it, is such a part of the healthcare system. I just expected it to have more cash moving through it.

All right. Other quick stats, 14,000 employees. Today, the market share is only 42% of hospitals, but it’s the largest and most successful hospital, so they actually have a bigger share of all care performed. 58% of ambulatory physicians now use Epic. 79% of the US ends up using Epic in one way or another.

In terms of profit, we heard a few different estimates. There are EBITDA margins somewhere between 30% and 35%, so just to be conservative, we’ll take that at the low end and say about $1.7 billion in EBITDA if those estimates are correct.

Then that brings us to what is Epic worth, which is a silly question because if you own shares, it would be very difficult to ever sell shares to anyone other than the company itself. So what’s the point of valuing something that you can’t own, and what’s the point of owning something that’ll never provide a financial return?

David: There’s never going to be a liquidity event for your shares.

Ben: But it’s worth doing. We started this episode talking about Judy’s one of the most successful, if not the most successful female founder of all time. Forbes has a list of this, of the most wealthy self-made women. I think their estimate is silly low.

David: Wildly wrong.

Ben: In 2021, Forbes estimates her net worth to be $7.6 billion. Implying that the company is worth $15 billion. That is a ludicrous valuation for Epic. If you do the very conservative thing of looking at Cerner’s EBITDA multiple of 30 times when Oracle bought them, and you assume conservatively again a 30% EBITDA margin at Epic, that would give you a number of $51 billion, valuing Epic at $51 billion.

But come on. Epic’s revenue streams are way more durable than Cerner’s. And Epic is growing while Cerner was going through a hard time. You could get to a similar number of that $50-ish billion if you just slap a 9x revenue multiple, which is a reasonable public market software comp. But this company has insane durability.

David: It’s missing the point that I think this is maybe the most durable software company in history.

Ben: My guess is if this is public, which it never will be, investors would value it somewhere in the $100 billion neighborhood, giving Judy’s shares a value of about $50 billion, making her the wealthiest self-made woman in the world, and one of the most successful entrepreneurs, period. That would put Epic in one of the most valuable 150 or so companies in the world, right along with Shopify, Arm, Lockheed Martin, and Starbucks.

David: Another thought exercise to come at this question is if in some alternate universe, Microsoft or Google or Amazon, or, I don’t know maybe even Berkshire Hathaway, maybe Apple, if they could acquire this company, how much would they be willing to pay for it? I think $100 billion is on the very, very low end of that spectrum.

Ben: That’s 4% of Apple or Microsoft. Of course, they’d be willing to pay 4% of themselves for this.

David: There’s the market. There’s the durability of the revenue and the profits.

Ben: Oh, I see. You’re arguing that on a financial basis alone, yes. And also the strategic value on top of that.

David: And the strategic value, both in terms of becoming the most important partner to this huge industry, to the biggest players in this huge industry in healthcare. But then also just the data in the AI world that we’re in today. My God, Cosmos, 15 billion patient interactions. You think Google or Microsoft or whomever wouldn’t pay a lot of money to own that. Of course they would.

Ben: Part of me is like, Ooh, thank God. Judy’s putting it in a trust.

David: All that to say this is never going to happen. So the final chapter of the story here is Judy’s 81 years old. What is going to happen at some point in the future? Even if she’s the next Warren Buffet here, we’re still talking about in the next couple of decades. There will have to be a transition.

Like you said, Ben, she owns about half the company economically and 100% of the voting shares. She has been transferring her non-voting shares into her foundation called Roots and Wings, so she signed the giving pledge and is transferring her wealth into the foundation. They then sell those shares back to the company at a price that changes every year, and that funds the foundation.

Judy has announced that upon her death, all of her voting shares, so the 100% voting control that she has at the company, will transfer into a “purpose trust” that will be administered by three constituencies: (1) Her family—her husband Godon if he’s still alive, and their three children, (2) A set of five longtime senior managers from Epic, and (3) I believe three customer CEOs, CEOs of big customers.

That group will manage the trust. In the trust bylaws are several things: (1) the company can never be sold or taken public ironclad. That can never happen. (2) The next CEO of Epic must meet two criteria.

Ben: Oh, be a software developer, right?

David: Yes. (1) Must be a long time Epic employee, and (2) must be a software developer.

Ben: I love the idea of the CEO being someone who came from the core skill of the company. It’s very Costco. You think about all the Costco CEOs have been people who were core to Costco’s operations over the years, and had worked there for 30+ years. Nike’s heyday was when a guy who started in sneaker design ended up running the company (Mark Parker). There’s a beauty to when that happens.

David: There is a playbook to this.

Ben: One last thing to know about Epic today, looking forward, we talked a lot about interoperability and their notorious lack of partnership or ability to access their data or integrate with them in the past. A lot has changed. But there would be a whole nother four hour podcast on specifically how there are many programs, each with different methods of integration, different names, different standards. They’ve all evolved over the years.

They come with things like revenue shares back to Epic. And if it is the rare true partnership, they can also come with warrants to own a chunk of your company. But the bottom line is you actually can do a lot more building on top of it, integrating with Epic, than you could have 10 or 20 years ago.

David: All right. That’s our Epic story. Should we move into analysis?

Ben: Let’s do it. The first part of analysis is a section called power, which we have shamelessly ripped from Hamilton Helm’s book Seven Powers. The question is, what is it about any given business that allows them to achieve persistent differential returns, or to be more profitable than their closest competitor on a sustainable basis?

There are seven of these. There’s counter positioning, scale economies, switching costs, network economies, process power, branding, and cornered resource. As usual, we have to separate the takeoff phase from the phase that they’re in today.

David, I’m curious. Do you have one for the takeoff phase? Do you feel like you can analyze why in the takeoff phase they gained power?

David: Well, it’s funny. They didn’t take off for quite a while.

Ben: And I might argue they didn’t actually have any power during the takeoff phase.

David: Yeah, I don’t think so. Ultimately, their biggest point of differentiation being the single platform, didn’t matter that much in that phase. Everybody else was starting up new, and they hadn’t built that much without it. There wasn’t that much computing adoption among hospitals generally, so didn’t really matter.

Ben: I think what was happening is they had this nascent market in the proto EHR world, where they were able to sell something small enough at enough of a profit to be self-sustaining while they bided their time and built out the bigger suite.

They were able to basically use time as a resource that most people don’t flex. Most entrepreneurs want to do something in a short period of time, usually because their capital structure demands it. You launch a platform and try to get other people to build the applications because you’re in a really, really dynamic, fast changing market. Or you launch an application on a platform that somebody else built similarly because you’re in a dynamic changing market.

Epic’s market was developing slowly over a long period of time. They were willing to run a small business for a long period of time, and then grow into building all the functionality for the eventual huge market that wanted all the functionality tied together.

So then what powers do they have today as the scale incumbent?

David: A lot is the answer. A lot. The most obvious one is switching costs. This is the biggest switching cost piece of software ever.

Ben: Ooh, that’s interesting. Is that true? Do you think it’s bigger than people’s ERP instance?

David: For sure. This is like an ERP on steroids. This is the most important nervous system for your entire business. Oh yeah, and by the way if things go wrong or it goes down, people die.

Ben: That’s a very good point. People spend, including all the opportunity costs and everything, hundreds of millions or billions to put this in. Are there any ERP or CRM implementations that cost $1 billion, $5 billion, $10 billion?

David: Maybe, but I don’t think any that are so core to everything about your customer’s business.

Ben: You’re right. Even if it was really expensive to put it in, you’re still more likely to swap out one of those systems than you are your EMR at this point.

David: It’s so much more than a medical record, yes.

Ben: So that’s definitely true. Scale economies is definitely true to the thing we were talking about a minute ago. You can’t make the investments in product breadth without having the scale that you have today.

You also can’t do their clever bundling in a bunch of free stuff that you might want to use in the future unless you have the scale economies also. They just develop a lot of software that they either throw in for free or offer to you in the future, and the only way you can develop that much software is have a huge number of customers to amortize it across.

If you’re trying to start a new EMR today, you have to write a lot of software to be competitive. And that’s scale economies.

David: Network economies, yup.

Ben: You bet.

David: You bet it.

Ben: They hit this interesting tipping point where they could win just on, we’re the best, most reliable platform for a long time. Then at some point, it hits some tipping point where there is a second value proposition, which is most other hospitals are also on Epic, so your patients and your doctors will all appreciate it if you adopt Epic to make it easier to interop with the records at all those other hospitals. Is like an icing on the cake.

David: Oh, you’re talking about interop. There’s interop, but there’s also, do you think you will need to hire more doctors in the future either to grow or as your existing doctors retire?

Ben: Pick the standard.

David: Well, what do they know how to use and what are they trained on? Epic. Great.

Ben: That’s true. It’s its second network economy in addition to the Care Everywhere concept of being able to share my records across institutions.

There’s one institution in Seattle that I go to for my son’s food allergies. They’re on Cerner. I have three institutions that I’ve gone to over the years for various other stuff that are all on Epic. I don’t know why that one hospital is still on Cerner.

David: It’s really annoying to you, isn’t it?

Ben: I’m sure everyone else in Seattle is like, why don’t you just do the thing that all the other big hospitals do so that it’s all the same platform? That’s network economies.

David: It’s amazing that they have built a network economy business. Who would’ve thought of medical software?

Ben: There is value to every participant in the system, from the other hospitals to me as a patient, to doctors. If that one holdout hospital that for some reason is on Cerner just switches to Epic, it’s a definition of network economy.

I think they also have branding. They’re the most trusted of all the most prestigious institutions, so at this point, if they had no other powers and they just came in and had identical bids on the table, 100% of the time people would say Epic because It’s going to work. I know your brand.

David: Don’t get fired for buying IBM, exactly. I didn’t think about that. I was like, oh no, they don’t have branding. It’s not really a consumer brand (MyChart), but no. You’re totally right. They totally have branding.

Ben: That is in part why they built that massive auditorium to bring the whole universe of Epic together every few months.

David: I think you could argue that they do have process power, I think is the last one I would say, in their development process, the language that they use, and it being unique to Epic. This is more of a defensive one.

Ben: I think it’s about the training of young employees, the way that they make them the Epic way.

David: Well, interesting, there’s the Epic way. I buy that generally, but I think specifically you can point to their software developers who they’re hiring out of college, mostly building on Caché and MUMPS, and they don’t—

Ben: Don’t develop transferable skills.

David: It’s not like you can easily then go work at Cerner and port that over. Sure you could if you’re a great software developer, you can learn other languages and other frameworks. But if you spent your whole career all developing in this proprietary Epic system, and I should say proprietary is the wrong word, they don’t make MUMPS or Caché. A separate company called InterSystems makes them, they license it from them. But most of the rest of the industry does not operate on that. It is a bit of a process power.

Ben: I think that’s fair. All right. That does it for power.

David: Great.

Ben: Do you have any playbook themes?

David: Yes, I do.

Ben: The one that jumped right out at me was the heavy spend on research and development. This one is from friend of the show, Arvin Navaratnam at Worldly Partners, in the always excellent writeup that he does associated with these episodes that we’ll link to in the show notes.

Epic, of course, builds, as we’ve talked about a million times, their whole systems from scratch. They don’t buy companies. It’s all in-house development. The result of that is 35% of their operating expenses are spent on R&D. If you compare this to Athenahealth, a competitor that’s 10% or Oracle all up is 23%, or if you look outside this industry, it’s actually equivalent to Apple at 36% of their operating expenses of R&D. Amazon’s 28%, so 35% is quite meaningful.

David: It’s quite high.

Ben: The only one that beats them is Google at 45%. Think about all the money that Google is just dumping into R&D for all these future-looking projects, and they’re a core technology company.

On the one hand, duh, because Epic doesn’t really buy other companies or spend any money on sales and marketing, and they keep their G&A low, so what are their other expenses? Of course, it’s going to be high on R&D.

David: Unlike most companies, they spend zero on sales and marketing. If they classify those eight people that they employ as “salespeople” as headcount, maybe they spend, I don’t know, not much.

Ben: Small. But I think to get to this point that we’ve been hitting in a bunch of different ways, as long as you can win deals in the short-term early days without sales and marketing spend, and you can just spend all of your costs or as much as possible on R&D, that R&D does compound over time to give you a big competitive advantage later in life that other forms of spend do not.

David: Especially in software.

Ben: My next one is about growth. I was reading an article that said Faulkner once described her approach as climbing a mountain, not trying to see the entire mountain at once, but by focusing on the next hill in front of her. It reminded me of something I’ve read before. Does this remind you of anything?

David: I’m drawing a blank. Go for it.

Ben: In Paul Graham’s legendary 2012 essay, Startups = Growth, he’s talking about how the whole thing you need to do as a startup is focus on next week’s growth.

He then says, “In theory this sort of hill-climbing could get a startup into trouble. They could end up on a local maximum. But in practice that never happens. Having to hit a growth number every week forces founders to act, and acting versus not acting is the high bit of succeeding. Nine times out of ten, sitting around strategizing is just a form of procrastination. Whereas founders’ intuitions about which hill to climb are usually better than they realize. Plus the maxima in the space of startup ideas are not spiky and isolated. Most fairly good ideas are adjacent to even better ones.”

I just thought, I don’t know. It just jumped off the page at me that Judy, who has almost certainly never read any of Paul Graham’s writings, had this same insight. I don’t try to see the entire mountain at once. I just try to focus on the hill right in front of me. And that hill is adjacent to a bigger and more interesting hill.

David: I’m so glad you brought this up. I was thinking about Judy as this incredible software developer, who became a founder of a company, this incredible business person, and didn’t follow any of the MBA rules.

Ben: Except that she did. She just discovered them all for herself in Wisconsin.

David: Well, right. I was thinking about it. I was like, man, her story in this company reminds me of Paul Graham and Y Combinator. There are so many residences here, but they’re also like a different world.

If Y Combinator weren’t about funding companies and being a venture capital firm, and instead were espousing to founders instead of raising money, build your companies independently without capital, we would have a lot more Epic systems running around out there. But she also built this in a different era where you could do this without capital.

Ben: I think that’s right.

David: But the distance between Judy Faulkner and Paul Graham is actually not nearly as far as you would think.

Ben: It’s applying computer science principles and common sense ways of running a company that are obvious to you but contrarian to the way that most people seem to run companies, and just being a programmer turned business person to its logical extreme.

Okay. One that we did not talk about is their litigation strategy. It’s worth just touching this so people are aware. They are aggressive on defending IP, and as they would put it on defense against patent trolls, they’re also extremely aggressive on employment practices law.

They have non-competes to keep secrets secret, and they enforce them. They are also why employers can force their employees into arbitration. They won a landmark case around forced arbitration.

David: Went to the Supreme Court, I believe.

Ben: They’re embroiled in lawsuits with other health IT companies trying to use Epic software in a way that Epic believes violates terms of service. There’s not one of these, there are a bunch of these.

David: Including an antitrust lawsuit. A big one with a startup called Particle Health.

Ben: That is at a really pivotal point right now. Yes, David, they are being accused of violating the Sherman Antitrust Act.

David: And that suit is ongoing.

Ben: We just put this out there to say, this company is seemingly not shy about using the law to protect things that they believe are theirs and to deepen their moat. Interestingly though, they have never been in a lawsuit or even in mediation with a customer. There’s a sacredness to that customer relationship that they hold really dear.

David: It comes back to when we were talking about the company culture. Everything at the company is about customers.

Ben: All right. The next one is one I call enterprise sales on steroids. Normally in enterprise sales you have a bunch of things: long sales cycles, stuff where the buyer’s not the user, so you end up with a kludgy UI.

It’s not just because people don’t care, but the breadth of enterprise software is really, really wide, so it takes forever to write everything. You’re not going to keep updating it every time there are new UI trends.

On top of that, a million screens look really similar for different users for different use cases, so they all just end up looking like dropdowns and buttons. Hard to blame someone specifically for that.

There are tons of customization, long implementation times. This is enterprise sales, and enterprise software generally, not in healthcare. Then in healthcare—here comes the steroids—you have the added layer of regulation from HIPAA, and other medical system compliance stuff, and data sensitivity, and lives are on the line.

In most industries, when you’re a startup looking down the end of the barrel and you’re like, all right, I am not doing this top down enterprise sales thing. I’m going to do product-led growth. I’m going to get some bottom-up adoption. We’ll play the Slack or the Figma or you name it.

But HIPAA makes product led growth much harder, so from the great substack, Health API Guy, under HIPAA regulations, a business associate agreement typically needs to be signed by someone with the proper authority to legally bind the organization, not individual providers or employees.

David, this is something I kept thinking, why doesn’t one doctor or one practice adopt something, then get bottom-up adoption, and that’s how we’ll get the next EHR in the future? No, these are all CIO sales because they all need to be.

David: You can’t have the typical, oh, a small team within a big company is going to buy this on a credit card. Nope. Not going to happen.

Ben: And there are some exceptions. I know there’s some PLG that happens in healthcare, but it’s way, way harder to figure out how to do that than normal B2B SaaS.

And my last one, Judy is a wacky, wacky founder. So is every truly great entrepreneur that we study. She is truly N of 1. She has stated that it is more likely that she’ll die than retire, just like Warren Buffet always jokes. She’s singularly focused on making Epic great in her life, just like Ingvar Kamprad and IKEA. She’s totally obsessed with rapidly incorporating feedback from customers just like Jeff Bezos. And she believes correctly that the nerds will prevail in the long run, at least correctly for her market, her point of view, her industry. She is completely unique in the way that all the great founders we study are.

David: You foreshadowed in the intro that Judy is almost certainly the most successful, by any measure, female founder in history. I think that is actually true. I looked up to try and see who else might even come close.

You could maybe make a case for Estée Lauder. However, despite Estée Lauder reaching about $100 billion market cap during the pandemic, it’s only worth about $20 billion today. I don’t know what happened there.

Taylor Swift and Oprah, which we’ve talked about, and we did our Taylor Swift update at the Chase Center Show last year. We think the enterprise of Taylor Inc is “only” worth about $11 billion.

Ben: I love that you and I have an ongoing Taylor Inc calculator.

David: Yeah. Oprah’s less than that. Forbes currently thinks that Diane Hendricks is the wealthiest female founder in the world, or at least in America. She’s the founder of ABC Supply, which is one of the largest roofing suppliers in the country.

Ben: You know what’s crazy? This means that the two most successful female founders in America are both based in Wisconsin.

David: I know. Isn’t that amazing? I thought I was going to say that. I love that you found that too. It is a big and great company for sure. However, ABC Supply does about $20 billion a year in revenue. I assume not anywhere near Epic’s margins, so I don’t think it is worth the (call it) minimum $100 billion that (I think) Epic is worth.

Ben: Ooh, you’re now up to a minimum $100 billion.

David: Well, I’m going by my rubric of if somebody could acquire this company, what would they be willing to pay?

Ben: That’s funny. If someone offered you shares in Epic right now at $100 billion, would you pay it?

David: Ooh, good question. If I could get profit distributions from Epic, yes, I would love to hold Epic shares for the rest of my life. I would for sure pay that.

Ben: I totally agree.

David: If I were banking on a liquidity event, then no. But me personally, yeah, I would love to hold shares.

Ben: When people are speculating on the value of something, the interesting way to turn it around is always okay, are you a buyer at that price? Open your wallet. Makes it feel much more real.

David: I would for sure buy shares of Epic at $100 billion. There’s no way I will ever be allowed to, but I would love to.

Ben: That sounds like a standing offer and the show is not investment advice. In this category, man, it is crazy how powerful founder continuity can be. I was thinking about this. How many other companies have had a single founder leader for 47 years? Jensen’s 31 years into NVIDIA. Zuckerberg is 21 years into Facebook. Obviously, there are a lot running smaller companies.

David: There’s Berkshire Hathaway.

Ben: That’s actually the exception. Buffet’s been running Berkshire for over 50 years. But in Judy’s case, having 47 years to imbue the founder’s personality into the organization as it’s built all the way to this scale is really rare and really powerful.

David: And as you’ve alluded to, she really is like Jensen, she’s still running the company. She’s still highly engaged.

Ben: Absolutely. All right, bear in bull cases?

David: Let’s do it.

Ben: All right. A few different things contributing to the bear case if I were to make one. US customers had very big dollars they could pay. The market is big because: (1) the US economy and population are large, and (2) unfortunately, healthcare is a large percent of that. If the future is coming from international, that could be less fruitful, much lower willingness to pay in most countries for healthcare administration stuff. That’s one bear case element.

The other would be if this particle suit ends up getting actually picked up and there’s a material event that happens for Epic around antitrust and a violation of the Sherman Act, that’s a huge, huge problem. That is a company-changing thing if that comes to bear, so we’ll have to watch the news on that.

The third is there is legislation that happened in the last few years about information blocking. There’s an act that passed called the Cures Act that essentially says that an EHR or health system cannot block access to information. Even though Epic makes a very reasonable argument around data privacy, security, and in the long run patient safety by locking down data, the Cures Act makes things like screen scraping or chrome extensions or RPA legal as a means to extract data from Epic. There’s nothing they can do about it that is required, allowed.

David: Interesting.

Ben: At this point, I don’t know how that could really displace them.

David: What also begs the question of yeah, what would you do? Okay, you scrape Epic data, you’re not going to build Epic.

Ben: Epic has always been hypersensitive about locking that stuff down for good reasons for their customers, but also for their own durability reasons. And I think this is going to be a tiny crack in the armor.

The fear is that someone deploys to 70% of your customer base, they’re all using some Chrome extension. They’re all feeding the data into some nice UI. That nice UI is the thing everyone prefers to use. Then that UI vendor’s like, oh, instead of using Epic on the backside, you could use my own home rolled thing on the backside, but the probability of that happening is near zero.

David: Not going to happen.

Ben: I’m not that worried about that. The other thing is maybe if interoperability comes to pass in a bigger way, then you could see the best of breed applications becoming a more dominant paradigm versus the all integrated paradigm. Again, this feels pretty handwavy to describe as the bear case.

David: Well, and should that happen, they still have the Microsoft playbook, which they absolutely run. Okay, let’s even say there are better best of breed point applications out there. Great. Mrs. or Mr. Hospital CIO, you could go pay money for those. Or you could just keep buying your Epic enterprise license where you get access to all of these point applications that you need for one price.

Ben: And then the last one is paradigm shift. This is always the bear case for any dominant company. Is AI going to be such a dominant paradigm shift that it changes the needs of health systems? Or is value-based care going to be such a paradigm shift that it changes what a health system is?

Maybe you don’t go to the doctor most of the time. I have a hard time even imagining what it could be that you wouldn’t need a system like Epic. Or maybe new care delivery models will make the old type of EMRs obsolete. This requires some imagination and again, it’s very handwavy. Epic also has their eye on all of this, so it’s hard to imagine any of those things being the—

David: Right. My question to you is going to be, okay, how much do you want to talk about AI here? Or how much do you want to talk about it in the bull case?

Ben: It’s probably more of a bull case.

David: All right, well let’s do a bull case.

Ben: Great. All right. The bull case is they’ve successfully expanded from EMR plus billing to all these other specialties and modules. They basically served all those same customers, even more products.

Those customers: (a) will need more products in the future, (b) there continues to be more health systems they can sell to, and now (c) they are expanding the customer base from just health systems to other types of companies—pharma, payers, researchers—from this new dominant position that they’re in. So they’re expanding to a whole new set of potential customers who could pay them because of their dominant position. I think that’s extremely credible. They could have an even larger business.

David: Prior auth seems like the first and most obvious business opportunity for them here.

Ben: In some ways, hospitals are crappy customers because they don’t generate much profit. Insurance companies are probably much better customers if you can figure out something really compelling for them. Unfortunately, again, I feel like every time I come up with some profit pool in healthcare, I’m like, boy, I really wish that wasn’t there. I’ll have to think philosophically on why I keep feeling that way. But definitely, I end up critical of anything that becomes too profitable in the healthcare system.

David: Behind that, though, is that we as consumers feel like some of these entities are not in any way providing value to us.

Ben: I feel like I’m getting ripped off. I saw a study that said 30% of spending on healthcare, in the 18% of GDP goes to waste, truly waste. I saw another one that quantified it and said $800 billion of waste is in the system. The entire GDP of Switzerland’s worth of waste exists in our healthcare system.

David: Sounds about right.

Ben: Another interesting thing that someone brought up is they asked me how much I pay in premiums a year for health insurance for the family. I was like, I don’t know. I think somewhere in the neighborhood of $25,000–$30,000. Their comment back was like, in what world are you ever going to use $25,000 or 30,000?

Don’t imagine what’s on the bill because that’s all made up. All the numbers are made up. The top line, the negotiated rate, what I am covered for, they’re all made up. Just imagine dollars out of your pocket for healthcare and don’t even just pick this year, pick a 10-year period because stuff might come up.

You’ll have surgeries in some years but not others. What are you actually willing to pay and go out of your pocket dollars, give a doctor for everything you need over the next 10 years, and compare that against everything you’re paying into the system. If you were to be paying your own employer side, employee side, and all the out-of-pocket stuff, we’re not getting a good deal. We’re just not. And we can all feel it.

Continuing the bull case, so there’s a whole category called ambient listening. One of the biggest complaints that people have with EHRs is doctors spend too much time in front of the computers. They’re typing in notes, they’re clicky clicky on nine different dropdown boxes and alerts.

Sometimes that gets fixed by having someone in the room typing while the doctor is doctoring with you. Either way, there’s the scribe. But the doctor’s also at a computer because they just need to read the medical records, so the doctor ends up in front of a screen. They’re wasting a bunch of time typing or they’re hiring someone to type.

Oh my God, AI would be amazing for this if only there was an ambient listening AI scribe that could be writing down and categorizing and structuring all the data that comes out of an interaction with a physician. Well, good news. It’s happening.

David: It is happening and it works.

Ben: David, there are a few companies that are partners of Epic, right?

David: That’s right. One is Microsoft and Nuance. Microsoft bought a company called Nuance a few years ago.

Ben: They used to do Dragon Dictation?

David: Yeah. They’ve always been in the voice space for healthcare. They now have an ambient AI product.

Then there are two big startups, one called Abridge based out of Pittsburgh, and then another one called Suki that have really good ambient AI products that plug into Epic, and yeah, are an AI scribe. People who use them, physicians who use them, love them. You can just focus on the patient and it scribes it all.

Ben: This would be a great solve to some of the doctor burnout, fatigue, and too much screen time that a lot of physicians are seeing.

David: That’s the bull case for this. These products are all partners of Epic, and in some cases, Epic may have relationships or warrants with some of these companies, or just revenue. You could also imagine Epic might want to build their own product to this someday. It’s a big opportunity.

Ben: Epic is the choke point of the industry at this point to decide what software innovations reach hospitals. I don’t think it’s overstating it to say if you’re developing new breakthrough software to be used by physicians in hospital systems, Epic’s the one that gets to decide, are you going to reach that customer or not.

David: Exactly. I think the basic bull case on ambient voice, ambient AI, is this is a great new product revenue opportunity. The mega bull case to borrow from our IPL episode here is one CIO was talking to me, he’s like, look, I don’t have high confidence that this is going to happen, but as ambient AI becomes better and better, is there a version of the future where the EHR “itself” just fades into the background and this all just becomes an AI operating system?

What is it primarily doing to EHR? It’s capturing data about what happened, it’s recording it both for clinical uses and then importantly for billing purposes. Then what needs to happen with that for billing purposes? Well, that data needs to get shipped over to the payer, whether that’s the government or an insurance company, and then needs to get judged and adjudicated, and then payouts need to happen.

Is there any real reason why this can’t all be done by AI in the future? Why do we actually really need user-facing software here? Or a lot of it. So yeah, there may be some future where, and this is a utopian type future, but a lot of the administrative bloat and costs in the system actually gets taken care of by ambient AI just sucking it all up here.

Ben: I’ll believe it when I see it, but it sounds nice.

David: Exactly, but a real CIO of a real big hospital system made this case to me.

Ben: It’s just so hard to believe bloat ever goes away. Getting administrative costs down is so hard. What are you going to do? Put a whole bunch of people who have good administrative jobs at hospitals out? That is going to be hard for our whole society.

David: For sure. This is the question about AI, right?

Ben: But you’re right. I think it’s a bull case if you’re a shareholder of Epic though.

David: If Epic becomes that system. All that to say, like every industry, AI has big potential here.

Ben: I think that’s fair, and that’s on top of everything we’ve already talked about. No one is switching off of them. Revenue from their install base will just continue to grow. They’ve become the standard that everyone will switch to once they get a customer. They don’t leave.

Honestly, at this point, regulation is probably also a bull case. This is what happens once you become an incumbent. Regulation tends to shut out new entrants and entrench the older companies because the older companies are the ones that have the resources to comply.

They’ve got their ears to the ground. They’ve got a ton of resources, so when new data interoperability stuff, like there’s one called TEFCA that is in the works, Epic can be the first to implement it well. That can further entrench them as they comply correctly with new regulations and new compliance.

As we talked about, there’s probably pricing headroom at this point, which may or may not be great for their customers but it’s great for Epic, and they probably can start extracting more value if they wanted to pull forward some of the future into today.

David: I would be really, really surprised if they do that.

Ben: I would too. I don’t think they will. Then the last one is becoming a platform. They really haven’t done this to date. They’ve built it all themselves. But I’m curious if they start platformizing a little bit more.

They’ve always had little things here and there (App Orchard), but I’d be curious if they at some point make a real play to be a robust platform layer upon which other applications build on top of. To your point about vertical software, maybe that’s just not the way this ends up playing out, but they have the opportunity if they want it and think it would be more valuable than their current path.

David: All right. Should we do quintessence?

Ben: The biggest question I have is why did it uniquely work in this field to build the entire platform and all the applications yourself? Any other time you get that pitched, pass. I’m not investing in that. That’s a stupid strategy. Why in this industry did it work?

David: I phrased this as a different question to myself, but I think it’s the same thing. I asked, why did Epic win? But I think it’s the same question here. To me it just smacked me in the head. This is vertical market software. This is the correct playbook to win in vertical market software, and it is very different from building horizontal market software.

Ben: That’s interesting.

David: Because in vertical market software, you are only serving one category of user. The deeper and deeper and deeper you can go into their business operations and solving their problems, the better. Whereas if you’re building Slack or Salesforce…

Ben: Let’s pick a horizontal complex piece of software. Microsoft Office.

David: Yeah. Microsoft Office. Great. Canonical example.

Ben: Or Windows actually.

David: Right. You need to be really, really, really careful about going too far into one customer segment. This goes all the way into product development. You hear all the time from really great product people and engineers at the big horizontal technology companies that the surest way to design bad products is to listen to your customers.

Ben: You internalize the feedback and then you decide what the best feature would be based on their own experience or based on collecting all the different experiences.

David: And that (I think) is generally right for building horizontal software and products. However, when you’re building vertical market software and products, you absolutely want to listen to your customers. That is what Epic is really good at.

Ben: That’s interesting.

David: You want to build exactly what they want. You want to understand who your customer is. And your customer is the CIO, the CIO, and the CFO of the hospital system.

Ben: I now agree with you. My answer, it probably just layers on top of why it’s healthcare-specific, not just vertical-specific. It is all the—we were talking about carrots and sticks earlier—all the sticks in this industry. If your software is bad, they die. The right thing is one big integrated approach rather than any risk at all of discontinuity between different applications, so that’s one.

Two is all the compliance stuff. Again, if you have any data leak, whoa, it’s catastrophically bad for HIPAA. If you don’t function correctly, oh you get your Medicare, Medicaid subsidies crushed for violating meaningful use stuff. There are just all these sticks with any mistakes. In a situation where you can’t make any mistakes, the single vendor playbook is the right playbook, even if it’s going to take 47 years to build the dominant company. You just have to write a lot of software and it all has to work together really well.

David: One of the things I was thinking about this idea of Epic as a vertical market software company, I don’t think we’ve ever really covered any other vertical market software companies on the show before.

Ben: I don’t think we have, either.

David: We sort of have. I was thinking about why that is. I’m like, oh well that makes sense. Generally vertical market software companies are not going to get that big. You’re limited by your vertical market. This is a rare case where because the market they operate in is so big, the American healthcare market…

Ben: And it’s something we all use.

David: And it’s something we all use and it’s something that is so important, you actually can get a really valuable company built serving just one end market. Then I was thinking about it and I was like, Epic has got to be the most valuable vertical market software company in the entire world. What else could possibly be up there?

I started racking my brain. I was like, Bloomberg was the only one I could come up with that could plausibly maybe be as valuable. We got to do a Bloomberg episode someday, but that’ll be our second vertical market software company that we cover. But then I was Googling and I was thinking about it. I was like, well people talk about Veeva Systems.

Ben: Yeah, Veeva, which is also healthcare.

David: They’re probably the largest public company. But I was like yep, they’re definitely not worth as much as Epic, and they’re also operating in healthcare.

Ben: They’re not worth as much as Epic?

David: No. It’s about a $20 billion market cap company.

Ben: Oh wow. Yeah, I don’t think so.

David: The only other company I could come up with in the vertical market software industry that’s also in this big league is Constellation Software, of course, fan favorite friend of ours.

Ben: But they bundled together a bunch of different verticals.

David: Exactly, there a roll-up. And I think some of their biggest companies are vertical market healthcare and healthcare IT companies within Constellation. Mark Leonard I’m sure is a big Epic fan. Or maybe not fan because he probably operates some competitors. I’m sure he has respect for Judy.

Ben: I am sure. She’s got a gold medal in the capitalism olympics, so you got to respect it. All right, that winds it down. Should we do some carve outs?

David: Let’s do carve outs.

Ben: Let’s do something fun.

David: All right, I’ve got two. I’ve got a regular carve out today and then I have a preemptive carve out.

Ben: Great.

David: My carve out today is a friend of mine turned me onto a very, very popular OG YouTube video that I had never seen. Ken Block, the rally car driver, did a YouTube video back in 2012 of San Francisco. They shut down the streets in San Francisco, and he did this incredible rally car 10 minute–long video through San Francisco.

It’s like watching the old movie bullet with Steve McQueen and the Iconic. But it’s like that with a 600 horsepower rally car driven by one of the best in the world. I can’t believe I’d never seen this before. I sit there like, my gosh. I know those blocks. I lived there. It was so cool. Amazing video. He sadly died recently in an accident, which is why I was back in the news. But I did some more research into him and I knew nothing about him before.

He was one of the co-founders of DC Shoes, the skateboarding shoes. He was one of the two co-founders. Then after they sold it to Quiksilver, he got into professional rally car driving, became one of the best professional rally car drivers, filmed this whole series of amazing videos in cities. Super awesome. I can’t believe I’d never seen it before. We’ll link to it in the show notes.

Ben: I don’t know anything you just said, so I got to go look it up because none of that made any sense to me.

David: It’s a short enough, very impressive video. Very cool to watch.

Ben: Sweet.

David: That’s my main carve out. Then my preemptive carve out is, I am so excited for the Switch 2.

Ben: Ah, if it ships, if they start taking pre-orders again.

David: Ah yeah.

Ben: Maybe by the time this comes out.

David: I’m not worried about it hitting the ship date. I think they have to sort out the US price and everything, but it looks incredible. Basically everything on our Nintendo episodes that we’ve hoped Nintendo would do with the successor system to the Switch they’re doing. Full backwards compatibility, maintaining the online accounts. System looks incredible. Shipping with a new Mario Kart. It’s going to be just awesome in and of itself. I can’t wait to have one for me.

Also my older daughter, I have been waiting since the day she was born to play video games with her. By the time it comes out, I’m thinking she might finally be ready for Mario Kart and I’m just so excited.

Ben: Sweet. Oh that’ll be so fun. All right, mine.

David: Go for it.

Ben: I just re-watched the movie Knives Out.

David: Oh yeah, good one. Daniel Craig.

Ben: Extremely fun, so good. It’s just pure popcorn. It’s visually stunning. Everyone loves a who done it? Daniel Craig’s awesome. The whole cast is great. If you haven’t seen that, you’ll really enjoy movie night.

My second one is I must be the last person to discover this album. I have been listening to the album Brat by Charli XCX. He is awesome.

David: Well you’re definitely not the last person because, don’t worry Ben. I will always be behind you in discovering music.

Ben: I just got to say, I am the oldest male list and also the fact that this came out 2024, everything about this is like a ridiculous carve out. I was watching Charli XCX at the Grammys in her performances there, and ever since, I’ve just had the album on repeat, and it’s amazing. It’ll transport you to another and much more fun world than the one you were currently sitting in in front of your computer.

David: I love it.

Ben: And then my last one is Odesza just released an album called Music To Refine To, and it is remixes from Severance. It’s just good. Leave it on lo-fi in the background while you’re doing work. I love Odessa. I love Severance. It’s my world colliding.

David: I’m grateful that all of us have you too. Keep us up to date on music here. My music is frozen in amber at 2006.

Ben: If you want to feel like you’re at a much cooler party than you’ve been invited to in 20 years, listen to Brat.

David: Great.

Ben: All right. One last thing, listeners. Remember, New York City, July 15th. We can’t wait to see you there. acquired.fm/nyc to make sure that you get the latest and you’re first to know as soon as we say what the heck is going on.

On that note, thank you to our partners this season. J.P. Morgan Payments, ServiceNow, Crusoe, and Fundrise. You can click the link in the show notes to learn more.

Thank you to all the people who spent time with us on this one. We talked to dozens of people and I think we can probably thank four or five of them specifically on air.

As always, Arvin Navaratnam at Worldly Partners for his great write-up linked in the show notes. Brendan Keeler who writes the Substack, Health API Guy, he’s awesome. Bryan Lawrence is the founder of Oakcliff Capital and was a great thought partner in this episode.

Lekan Wang, a healthcare technology investor and managing partner of JSL Health Capital. Scott Gaines, a longtime IT executive from Highland and CoverMyMeds. Patrick Wingo, the head of research at Elion, someone who has studied the health IT space very diligently and formally at Palantir.

John Bertrand, the CEO of Digital Diagnostics, an advisor at 8VC and a former Epic employee. He really helped me understand the culture and what a unique place it is to grow and develop there. And to Dr. Abed Meir, a Stanford physician and investor who used Epic firsthand before becoming an investor, and was inspired to become an Epic shareholder himself. David, I know you’ve got a few folks as well.

David: A whole number of health system CIOs who I spoke with. Huge thank you to all of you. One that I wanted to call out specifically was Mike Pfeffer, the CIO of Stanford Medicine.

Two fun ones, two of Jenny and my friends from our Princeton undergrad days who are now doctors at big Epic sites. Molly Kantor, who’s a doctor here at UCSF in San Francisco, and Carine Davila who is a doctor at MGH, at Harvard MGH in Boston. Got to speak with both of them about the physician experience using Epic.

Then finally we have a number of people to thank at Epic itself. Since there really isn’t any canonical long form piece about the company out there, we thought, we usually don’t do this, but let’s just email Judy and see if we can chat. And yes, she responded and we did.

Ben: Thank you, Judy, for spending time with us and helping us understand all the missing details we had on Epic’s company history. And of course also to Carl Dvorak, Sumit Rana, and Lee Lavonne, also from Epic who spent time with us and walked us through the history.

David: Yeah, we really, really appreciate it.

Ben: Listeners, if you liked this episode, go check out anything else in the acquired back catalog. We should specifically call out Novo Nordisk if you are into the healthcare space. You’ve also got lots of interviews available on ACQ2. Our most recent one was a conversation with Bill McDermot, the CEO of ServiceNow.

After you finish this episode, come discuss it with other smart Acquired Slack members, acquired.fm/slack. And with that listeners, we’ll see you next time.

David: We’ll see you next time.