I get this question from innovators entering the health tech space all the time: "Why are health systems still migrating to Epic?"
It's a fair question. On paper, Epic seems like yesterday's technology:
- Not cloud-native: health systems must either host it themselves or pay Epic for hosting
- Usability complaints: many providers grumble about clunky design and cumbersome workflows
- Walled garden architecture: its closed ecosystem limits innovation and slows technological adoption
So why does Epic continue to win? Last week at NJDVHIMSS, I spoke with health system technologists deep in Epic implementations. Their answer surprised me, as it's only partly about the technology.
The Real Story: How Epic Built Its Moat
Epic started as one of many electronic health record systems. What distinguished it was not flashy features but rather the ability to feel "custom" across specialties without requiring custom code. For large health systems managing cardiology, oncology, pediatrics, and other specialties, Epic offered breadth and depth that appeared comprehensive at what seemed like a reasonable cost.
Then the momentum began, creating reinforcing dynamics that have proven difficult to reverse.
1. Reliability as a Feature
"It just works," one implementation consultant told me. In healthcare, where system downtime can have serious clinical consequences, Epic's track record for performance and security is highly valued. Self-hosting is not a limitation but rather a feature. Health systems seek control over their most critical infrastructure, and Epic delivers operational predictability.
2. Network Effects
Epic's Care Everywhere platform enables seamless hospital-to-hospital data sharing. When a patient moves between Epic-enabled systems, their records follow. As more health systems adopt Epic, the network becomes more valuable to everyone in it. It's the classic network effect, where each new adopter makes the platform stickier for existing users.
3. Ecosystem Dominance
Epic has established a presence throughout the healthcare workforce pipeline. Certification programs create a labor force trained specifically in Epic workflows and functionalities. Medical education at major academic centers introduces students to Epic early in their training. When hiring decisions favor candidates with Epic experience, the cycle reinforces itself, further entrenching Epic's position.
4. Switching Costs Are Substantial
Migrating away from Epic is not merely expensive but organizationally disruptive. Years of customized workflows, integrated systems, and staff training create substantial inertia. The question facing health systems often becomes: "Can we afford not to stay?"
5. The Gold Standard Effect
Epic has become synonymous with "enterprise-grade EHR." When health system boards evaluate options, Epic represents the safe choice. No one gets fired for choosing Epic. This is a case study of economies of scale in software.
What This Means for Innovators
If you're building in health tech, Epic's dominance is unlikely to diminish in the near term. If you're hoping to sell or work within large health systems, the relevant question is not "How do we replace Epic?" but rather "How do we build in Epic's world?"
The pragmatic approach is to design for interoperability. Build tools that integrate with Epic, extend its capabilities, or solve problems Epic cannot or will not address. The walled garden has gates; success requires understanding where they are and how to navigate them.
Epic prioritizes breadth over depth. It covers every specialty enough to be functional, but rarely goes deep in niche clinical workflows (e.g., dermatology imaging, fertility tracking, or rehab therapy planning). It also provides analytics tools (e.g., Population Health modules) to support value-based care, but it’s not going to take on risk contracts, become a provider group, or function as a payer.
Epic's competitive advantage extends beyond technology. It is built on reliability, network effects, workforce training, and organizational inertia working in concert. Understanding these dynamics is essential for anyone seeking to operate effectively in the healthcare IT landscape.