How Google EHR Could Fix One of Healthcare’s Epic Flaws

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Design and Tech.Co

7 min readApr 19, 2019

Measles is prominent in the news due to an outbreak comprising, as of April 11th, 555 cases across 20 states. [1] This outbreak prompted a Congressional hearing on February 27, 2019 titled: “Confronting a Growing Public Health Threat: Measles Outbreaks in the U.S.”

We would argue that MUMPS, rather than measles, is a much bigger threat to America’s public health.

Mumps generally refers to two things:

a contagious and infectious viral disease causing swelling of the parotid salivary glands in the face, and a risk of sterility in adult males
an acronym for Massachusetts General Hospital Utility Multi-programming System (MUMPS) created in 1966 for the healthcare industry

While mumps in definition #1 has been largely eradicated through child vaccination programs, MUMPS, the programming language, has “infected” the information systems of our nation’s leading hospitals and is continuing to spread at an alarming rate. Having been designed in 1966, MUMPS is reasonably considered to be an archaic programming language, so the fact that it has managed to survive and prosper in some of the most technologically advanced hospitals in the U.S. deserves an explanation.

Epic Systems Corporation (“Epic”) is the leading purveyor of MUMPS-based software in healthcare. EPIC sells electronic health record (EHR) systems to large healthcare organizations. Close to 28% of the U.S. hospitals [2] and all of the nation’s top-20 hospitals use Epic. [3] Epic is also the leader in outpatient setting, with a 34% market share. [2]

Outdated, obsolete and incredibly expensive

Epic’s MUMPS-based technical architecture has been described as outdated and obsolete even by its current and former employees, with quotes including: [4]

“They use outdated tech that leaves you behind other people when it comes time to try applying elsewhere. Their development practices are equally far behind.”
“Many of the languages used are obsolete, and the tools used were primarily developed in house so they do not transfer over anywhere else…”
“The work is okay and the colleagues are super friendly, but adherence to outdated technology means that career advancement opportunities are next to nothing.”
“Severe technological debt makes development a pain and is very unrewarding. The company is deeply entrenched in Visual Basic 6 and Cache/MUMPS.”

Despite its outdated technology, Epic is considered to be the most expensive EHR system, with customers spending enormous sums of money on implementing the system. Examples include $4 billion spent by Kaiser, $1.2 billion by Boston’s Partners Healthcare, $700 million by Duke University Health System and $150 million spent by the University of California, San Francisco. [5]

Nobody gets fired

How is it possible that an archaic and incredibly expensive software platform is being embraced by the top U.S. hospitals?

We believe that there are two main reasons for why this is the case:

Epic is the “best in class” solution (in a very sorry class)
Nobody (or almost nobody) gets fired for choosing Epic

In January 2019, Epic was named the “Top Overall Software Suite” for the ninth consecutive year in the Best in KLAS 2019 Software & Services report. KLAS Research is a healthcare IT data and insights company.

Epic was also the Best in KLAS winner in 2016. This is despite the fact that the same year, Epic scored 3.38 out of 5 in EHR satisfaction on a Medscape survey of 15,285 physicians. In fairness, Epic’s closest competitor, Cerner, scored 3.04, and the third-leading competitor in the hospital EHR space, Meditech, scored 2.81. [6] As the saying goes, “In the land of the blind, the one-eyed man is king.”

“Nobody gets fired for buying IBM” was a common refrain among corporate CIOs for many years. It reflected the idea that if you go with a market leader, it will be hard for others to question your decision if you make a mistake. Among hospital CIOs, the common thought appears to be that “nobody got fired for buying Epic.” [7]

Epic problem for our healthcare system

The problem with Epic’s growing market share is that the company has been regularly criticized for stifling innovation by running a closed-box ecosystem that handicaps third-party developers trying to interface with its software. [8, 9]

For example, in the San Francisco Bay Area, which is a hotbed of healthcare IT innovation, there is a running joke among healthcare IT entrepreneurs.

Question: “Where do healthcare IT startups go to die?”

Answer: “To a hospital.”

Epic, which has a dominant presence in the San Francisco Bay Area hospitals, is often named as the inspiration for this joke for making it very difficult for healthcare IT startups to integrate with its hospital EHR system.

As a result of its archaic technological underpinnings and resistance to third-party innovation, Epic users — healthcare providers and patients — are saddled with a clunky user interface and user experience that consumers find unacceptable in a non-healthcare setting. For example, as a first-hand patient experience, when we recently attempted to use Epic’s MyChart Portal at UCSF Medical Center, we were unable to click through a screen that asked for a confirmation of communication settings. When that screen went away after 10 clicks, we spent 20 seconds waiting for a medication refill screen to load. Clicking on another link was followed by a time-out error. This type of a user experience would be completely unacceptable for an Amazon.com shopper.

Therefore, it is not surprising that 71% of doctors view electronic health record (EHR) software, including Epic, as contributing greatly to physician burnout [10]. The biggest complaints appear to be poor user interfaces (72% of doctors believe this is the biggest area of improvement needed) [10], poor interoperability [10, 11], and low usefulness as a clinical tool. [10, 12]

Information is a critical input for delivering healthcare. Therefore, having a comprehensive and easy-to-use electronic health record (EHR) is critical for providers to be able to deliver high-quality and lower-cost care. For the reasons discussed above, we believe that Epic’s dominance presents a significant obstacle to this goal.

Google to the rescue?

Google’s healthcare efforts have been in the news lately following its hiring of Dr. David Feinberg, the visionary former CEO of Geisinger Health System. Dr. Feinberg is expected to unify and lead Google’s healthcare efforts in bold new directions, which we hope includes a Google EHR.

When we refer to a Google EHR, we do not suggest reviving Google’s past failed attempt at creating a consumer-driven patient health record. We are, instead, suggesting creating next-generation clinical software to compete with Epic’s EHR product.

Google has an unmatched collection of assets to disrupt the EHR segment, and by extension, healthcare. These assets include Google search (the #1 software tool used by patients already), integrated and secure email, voice and video communication and collaboration system (G Suite), Google Cloud Platform, speech recognition, big data and machine learning expertise, interconnectivity/API expertise and platform, Android/mobile devices, at-home connectivity devices (Nest and Google Assistant) and a large ecosystem of proven third-party application developers. With these software and hardware assets, Google also brings a track record of great user experience AND financial resources to drive adoption by being able to offer the software at a low cost to hospitals and other providers.

In addition to the benefits of providing an integrated, interconnected and high-quality user experience for providers and patients, Google EHR would also provide quality raw data for a dramatic advancement of healthcare machine learning / artificial intelligence (AI). Machine learning / AI has the potential to dramatically improve prevention, diagnosis and treatment of health conditions. However, presently, the development of this technology is slowed by the poor quality and silo’d nature of information stored in current EHR systems.

Google has a track record of going up and winning against dominant incumbent software makers. For example, in web browsers, when Google Chrome for Windows launched in December 2008, Microsoft’s Internet Explorer had close to 70% market share. In just 11 years, Google Chrome captured more than 60% browser market share causing Microsoft to discontinue making new versions of Internet Explorer.

Google Chrome won by providing a fast, easy-to-use, lightweight solution, and rapidly iterating on the initial offering in response to customer feedback, something that the slow and bloated Internet Explorer could not do. We see an analogous opportunity with the Epic-dominated EHR market today which Google can exploit to the benefit of patients and providers alike.

So, hey Google, what do you say?

Last updated: 4/19/19

How Google EHR Could Fix One of Healthcare’s Epic Flaws

Outdated, obsolete and incredibly expensive

Nobody gets fired

Epic problem for our healthcare system

Google to the rescue?

References

Written by Anatoly Bushler