The Future of Madison’s ‘Epiconomy’
Our town has hooked its star to the software giant's success. But what happens when founder Judith Faulkner leaves?
Like Beyoncé, Oprah and Rihanna in the entertainment world, Judy in the Madison-area tech world is the singular name everybody knows, hugely respects and sometimes fears. She is Dane County’s tech superstar. Farsighted, detail-oriented, obsessive yet collaborative, Judy is just like these other titans. She is a true phenomenon.
So, yeah, there was an excited buzz in the air at Memorial Union’s Shannon Hall last year on Sept. 14 as Judith Faulkner, founding genius of the Verona-based medical software giant Epic Systems Corp. (2019 revenue: $3.2 billion), made a rare public appearance at the Cap Times Idea Fest.
Folks were leaning in, including me. Faulkner, the richest female self-made tech billionaire in America according to Forbes, keeps a decidedly low public profile in her community. But here she was for 40 minutes or so giving what was described as the inside story of 40 years of Epic success.
And so with humor, passion, PowerPoint and a well-polished narrative befitting her epic story (Faulkner is enamored with odes of perseverance), she uncoiled her tale of tech dominance. Of how more than half of Americans have their health records on Epic software. Of how 20 of the 21 largest health systems in the country are Epic customers. Of how putting those customers and their needs at the heart of its work is the key to Epic’s success.
We learned it all began in her student years as a math major at Dickinson College in Pennsylvania. With a summer internship Faulkner described as “totally a fluke,” she stumbled into computer programming. And she had a knack for it. Graduate studies brought her to Madison and to founding what became Epic Systems in 1979 with one-and-a-half employees.
She was “a normal programmer,” she told the audience. She cut her own hair. Wore jeans and sweatshirts. But she had the goods: ownership of a database she had created to run several University of Wisconsin–Madison departmental operations. (Called Chronicles, it remains at the heart of Epic’s software.) She also had early customers that became investors. For $7,000 they got 10% of the business.
“And they got good returns!” Faulkner said to a gale of laughter.
But Faulkner had her own secret sauce: a fierce sense of how Epic should be run.
Enshrining customer service. Not getting distracted by side ventures. Being honest. Not cutting deals. Never, ever giving up. But yet — having fun. And always, always staying privately owned. Because going public would betray the Epic mission.
That betrayal would mean focusing on quarterly dividends to satisfy Wall Street — money that would otherwise fund Epic’s expansive research (software development accounts for 38% of Epic’s expenses) that ultimately serves the needs of customers.
Sentiments like these have girded the Epic culture for decades. “We have our commandments. We have our principles,” Faulkner said. “It’s important to not just have them, but to ritualize them.”
So until the terrible dislocations of COVID-19 upended the carefully structured Epic world, Faulkner would convene a monthly meeting of the entire Verona staff of roughly 9,600 people at Deep Space, an extraordinary underground, 11,400-seat auditorium nestled in the expansive Epic campus. Another 1,200 employees based overseas or in other U.S. locales would watch remotely or later through a recording.
Attendance was mandatory with few exceptions. Team building was always the goal. Review of an Epic “commandment” and “principle” were always agenda items. Such as Commandment No. 8: “Have courage. What you put up with is what you stand for.” And Principle No. 9: “Do what is difficult for us if it makes things easier for our users.”
“We think it’s important for retaining culture,” Faulkner told the Idea Fest crowd about the monthly meetups. “It’s huge. And we make it fun.” Fun? Did she say fun? My first thought: Faulkner is like a bouncy but vaguely threatening HR character you might see spreading fear in an episode of “The Office.”
But fun is truly part of Epic’s hard-work equation.
Faulkner has this unexpected streak of childlike whimsy and is unembarrassed by it. Whimsy inspires the fairy-tale treehouses, the wizardry design flourishes and Star Wars nomenclature of the 1,041-acre Epic campus. But whimsy aside, Faulkner also has a deep understanding of how a well-designed work environment can spark creativity and productivity.
Hearing her expound on her epic vision and philosophy made for a quick 40 or so minutes. No questions were entertained. (That was disappointing and perhaps revealing.) Faulkner was certainly impressive, and not just for her insights either. Long-haired and loose-limbed, she looks a good 15 years younger than her chronological age of 77.
But inevitability approaches. The passing of a charismatic founder is always fraught with dangers for a successful company. What happens when Faulkner no longer directs the show? Can Epic maintain its market dominance? Will her singular vision endure?
Faulkner, who is nothing if not self-assured, thinks she has a plan — how else to put this? — to guide Epic from the grave. In March 2015, she announced she would gift nearly all of her Epic stock to a private charity tentatively named the Epic Heritage Foundation. The proceeds would fund nonprofit health care and education.
More to the point, she told Modern Healthcare magazine, “The foundation will control the stock. This plan is designed to preserve the company as a private company forever.”
Operational details are fuzzy, though. Assuming the foundation will be sitting on hundreds of millions of dollars in stock (if not more), how does it generate sufficient cash to meet the IRS requirement that it distribute at least 5% of its endowment every year?
We’ll apparently find out when the curtain is opened.
Given that Epic is by far the biggest private employer in Dane County, the broader community has a sizable economic stake in the success or failure of Faulkner’s grand plan. That’s one reason why the outright debacle of Epic trying to prematurely return its remote-working staff to the Verona campus was so shocking. Judith Faulkner, one of America’s great entrepreneurs, had made a spectacularly bad decision.
“We need 10 more Madisons,” Mark Muro, a senior fellow at the Brookings Institution, told the Milwaukee Journal Sentinel last December.
The think tank had just released a major report warning that a “winner take most” economic wave had concentrated — to an extraordinary degree — the nation’s booming tech-innovation industries in just five dynamic metro areas: Seattle, San Francisco, San Diego, San Jose and Boston.
Brookings argued diversification is sorely needed. Proposing a huge federal investment in seeding new tech centers across the country, the think tank weighed likely candidates — cities like Pittsburgh, Salt Lake City, Columbus, Nashville, Charlotte and Kansas City — on a half-dozen different criteria.
Darned if metropolitan Madison didn’t finish in first place and by a wide margin. Credit Madison’s concentration of smarty-pants residents with science/tech doctoral degrees, its high percentage of “innovation sector” jobs (like Epic’s army of software writers), patents awarded and UW–Madison’s longtime ranking as a top 10 research university.
These are the signposts of the Madison area’s extraordinary economic transformation over the past 35 years. For decades and decades, Madison was a cosseted government town sustained by state and UW jobs augmented by Oscar Mayer’s meatpacking operation, large insurance headquarters and a few lingering manufacturers.
By the early aughts, change was in the air. Backpack entrepreneurs and techies had become the cool kids on campus. “The Epiconomy,” as marketing executive Andy Wallman coined it, had taken hold in Madison. It only grew stronger with Epic’s continued expansion. Staffing climbed steadily from 29 in 1990, to 133 in 1995, to 400 in 2000, and then leapfrogged to 2,050 in 2005 and to 8,100 in 2014.
“They are recruiting the world’s best and brightest and bringing them to Madison,” says Zach Brandon, president of the Greater Madison Chamber of Commerce. He hails them as the building blocks of the new Madison economy.
Brandon and I talked in June. Two months later, the world had flipped over. Epic’s millennials rose in protest to Faulkner’s back-to-campus order, drawing unflattering national news attention. Epic’s and Madison’s brand were suddenly looking tarnished. Several tech observers I interviewed expect Epic recruitment to suffer.
“Epic has a tradition of hiring directly from college and molding their workers the way they want them,” says health-tech commentator John Lynn, founder of Healthcare IT Today. “I think the [campus furor] will ward off some of those graduates.”
Millennial workers “have high expectations of employers ‘hearing them’ and meeting their expectations around workplace culture and practices,” says Jennifer Pendergast, a Northwestern University business professor and faculty director.
So many other prestigious tech companies are moving toward enabling remote workers, she points out, while Epic is fighting the trend. Pendergast questions what kind of counsel Faulkner is receiving to have so badly misjudged the situation.
“I think the controversy would definitely affect recruitment,” she says, citing how young workers closely follow the anonymous workplace comments their peers post at Glassdoor and other job-review sites. “And the fact that [Epic’s turmoil] is in the news doesn’t help.”
Getting Epic to talk about itself is sometimes impossible. Famously insular and used to setting the terms of engagement, Epic is only occasionally media-friendly. For this story, Epic would respond only in broad strokes to written questions, which ruled out clarifying follow-up questions in time for print. (Watch for a follow up Q&A with an Epic representative to drop soon on madisonmagazine.com.) In years past for Epic pieces I’ve written, I was granted access to top executives Carl Dvorak and Stephen Dickmann. For this story I relied on knowledgeable outsiders and the public record.
This includes Toni Sikes, a serial entrepreneur who co-founded CODAworx, which connects artists with real estate developers, government officials, corporations and others who want to commission arts projects for their properties.
“You can’t imagine how much it has meant for me, as a female entrepreneur, to have the most successful businessperson in Dane County be a woman,” Sikes told me in an email. “Judy Faulkner is a pioneer and an inspiration for all of us tech entrepreneurs working in the trenches — but especially for the women.”
Note she says “inspiration” and not “mentor.” Sikes, an indefatigable presence in the Madison tech world, is a longtime volunteer adviser for MERLIN Mentors. This private, UW–Madison-supported group of savvy tech veterans offers free counseling to young entrepreneurs.
Faulkner has not done much mentoring. Nor has Epic funded venture investments in young companies in Madison or elsewhere that might diversify Epic’s reach.
This gets back to Faulkner’s avoidance of what she perceives as distractions. At Idea Fest, she told the Greek parable of the golden apples. Atalanta, the swift huntress, offered to marry any man who could outrun her, only to be done in by her own greed when her suitor cleverly rolled golden apples in front of her that she stopped to pick up. Atalanta lost the race, something that Faulkner says won’t happen to Epic.
Faulkner’s stewardship has prompted other questions. She and her husband Gordon Faulkner, a retired pediatrician (they have three adult children), are heavy contributors to liberal political candidates in both state and federal elections. Yet Epic has engaged in several lengthy legal battles to beat back assertions of worker rights. This includes a case that ended in a notable U.S. Supreme Court decision that ruled workers give up their right to join a class-action lawsuit against their employer if they sign a binding arbitration agreement as part of their hiring.
Rewire.News pungently headlined its May 2018 story: “US Supreme Court Hands Down an ‘Epic’ Blow to Workers.” The ruling did not slow recruitment. Epic reports adding 1,300 new employees between March and early August this year. But that court decision was a one-day news event. It did not put people’s lives at risk.
“Epic gets a hundred thousand applications a year for just a few thousand potential job openings,” Brandon says.
Historically, the company has hired high-achieving college brainiacs, steering clear of older, more experienced candidates whose work habits are shaped by other corporate cultures.
Epic’s pace is demanding but the pay is good. Glassdoor, the jobs and recruiting website, says Epic pays software developers up to about $181,000 a year, project managers up to about $196,000, client trainers up to around $79,000 and technical solutions engineers up to $97,000 a year. The burnout rate is high by all accounts. Many of these Epic expats hang around town waiting out the one-year (or longer) noncompete clauses that block them from doing Epic-related work. Many wind up staffing the second wave of Epic-connected enterprises: the consulting companies — Nordic Consulting Partners, Bluetree Network, Evergreen Healthcare Partners, Sagacious Consulting and others — that sweep into a clinic or hospital to assist in an Epic installation or to “optimize” the newly installed Epic software.
They, in turn, are part of a much larger health-tech Madison-area ecosystem involved with cutting-edge diagnostics and therapeutics, including breakout star Exact Sciences and its colon-cancer testing kit; longtime medical imaging stalwart GE Healthcare; HealthMyne, whose software analyzes scans and X-rays; and Propeller Health, whose digital sensors help patients control asthma and other respiratory diseases.
Add in the impressive medical-research and -teaching cluster that has grown up around University Hospital on the west end of campus, and you have nothing less than the foundation of Dane County’s 21st century economy.
With Epic as the flag waver.
“To have a company with Epic’s scale of success send a signal to the whole world that companies can succeed in this town,” says John Neis, executive managing director of health care-focused Venture Investors LLC. “It puts us on the map in a very unique way.”
Brandon sees an ongoing “seismic shift” in community identity. “Epic is not an anomaly in Madison,” he says. “It is not lightning in a bottle. It is instead the most notable point on a trend line. Madison has the potential to be the next technology superstar.”
Brandon adds that the community could be Seattle without the housing crisis and Austin without the traffic problems. “We want Madison to be a national center for health innovation.”
Brandon is impassioned when he says this over the phone. There’s a moment when he catches himself and confides he’s not blowing smoke. Really. Truly. This future is within our grasp, he insists.
In 2011, Harvard economist Edward Glaeser published the book “Triumph of the City: How Our Greatest Invention Makes Us Richer, Smarter, Greener, Healthier and Happier,” a compelling argument that cities worldwide are engines of innovation and opportunity. They’re a beacon that attracts the smartest and most entrepreneurial people as well as the poor and the immigrants who seek a new life.
The most successful cities — think New York, Chicago, Boston, Seattle and San Francisco — periodically reinvent themselves.
They find a new economic driver when the old one weakens and fades. Port cities become transportation hubs, which become manufacturing centers, which become tech havens or financial capitals. Rust Belt cities like Milwaukee and Detroit, or the old mill towns of the east and the mining towns of the west, tell a sadder story of stasis and decline.
Madison is a repeat winner. Not just now in the early 21st century, but in the late 19th century. That’s when “the Athens of the Midwest,” as the city’s patrician leaders saw their bucolic university town, belatedly opened up to the dirty smokestacks of industrialization. This was the much fought over “Madison Compromise” that reset the community’s economic course.
David Mollenhoff captured this pivotal moment in his indispensable book, “Madison: A History of the Formative Years.” An east-side factory district, whose durable bones remain evident to this day, was carved out for manufacturing, while the west side would be kept pristine for the professors and the professional class.
Enter John A. Johnson, a Norwegian immigrant, entrepreneur, progressive leader and former bartender. He was the Judy Faulkner of his day. Johnson brought the high wages of the manufacturing economy to a town that was in danger of being left behind in the industrial age. (Madison’s population of just under 20,000 trailed La Crosse, Racine and even Sheboygan in 1900, while booming Milwaukee had 14 times more people than Madison.)
Johnson’s factory — on the 1400 block of East Washington Avenue — stamped out plows and cultivators that were loaded on train cars and shipped to Great Plains wheat farmers. Across the street, Johnson opened the Gisholt Machine Co. — an early business-to-business enterprise that made high-value tools for America’s factories. (Amazon’s Shopbop now occupies much of the complex.)
“The agriculture implement and machine tools industries comes as close as anything I know to matching Epic’s transformative impact on Madison,” Mollenhoff says.
Both benefited mightily from federal subsidies. In Johnson’s case it was the Homestead Act giving millions of free acres in the West to settlers who farmed the prairie. In Faulkner’s case, it was President Barack Obama’s decision in 2009, as part of his economic stimulus plan, to subsidize the health care industry’s move from paper records to electronic health records, called EHRs.
Thirty years in the business, Epic was perfectly situated to dominate the new industry.
It did and it does. But the EHR results are mixed, despite the feds pumping in $36 billion in subsidies. And that’s a big reason why, in the long run, Epic could be vulnerable to challengers.
Epic’s great success is its peerless integrated electronic platform for hospitals and medical clinics to manage myriad programs.
This ranges from cranking out bills to storing patient medical records to creating a seemingly endless number of discrete, finely tuned “modules” to administer everything else.
This includes outpatient scheduling, cancer treatment, emergency room operations, patient financial assistance, organ transplants, insurance claims, e-communications with patients, lab tests and tons more. And, yes, Faulkner’s foundational Chronicles database still runs most programs.
Cerner, a giant publicly traded EHR provider in Kansas City, Missouri, with a larger foreign footprint than Epic (2019 revenue: $5.7 billion), is Epic’s closest U.S. rival. There are a handful of smaller competitors. None come close to matching Epic’s sky-high, year-after-year customer-satisfaction rankings. Is this vindication of the Epic way? In spades, according to health IT insiders.
“Epic has a tightly focused view. It is them and their customers,” affirms Niko Skievaski, an Epic expat who went on to co-found Redox, which facilitates health data exchange among IT platforms. “The customers are the heroes. They are on the pedestal. That’s what you’re taught at Epic.”
Says Jeremy Schwach, another Epic expat and Bluetree’s CEO, “Epic wins because its software works better than any other software out there.”
Neis points to Faulkner’s “incredible singular focus to be the best. That kind of passion and drive is phenomenal,” he says.
Mark Bakken, another venture capital investor and Nordic’s founder, cites Faulkner’s steadfast mission: “She’s doing [EHRs] to change the world. To save lives. To cure people.”
The problem — and it’s hard to refute — is that the promise of electronic health records was wildly oversold as a panacea for what ails American’s costly and often malfunctioning health care system.
David Blumenthal, the former federal coordinator of health information technology, wrote rapturously in 2009 of a coming “electronic circulatory system for health information that nourishes the practice of medicine, research and public health,” making the public healthier and doctors better at their jobs.
That same year President Obama drew heavy applause when he told the annual meeting of the American
Medical Association that electronic records “will not only mean less paper-pushing and lower administrative costs, saving taxpayers billions of dollars; it will also mean all of you physicians will have an easier time doing your jobs.”
Little of this happened.
Consider that in 2009 annual health care expenditures were at $2.5 trillion. By 2018, U.S. spending jumped to $3.6 trillion. By 2028, the feds project $6.2 trillion in health spending. As for the “electronic circulatory system,” a civil war was fought over how freely it should flow. Accused for years of maintaining a chokehold on patient data, Epic lost the war earlier this year when the feds adopted new rules that strengthen the rights of patients to control their health records and to share them with third-party app developers. (Epic hotly denied it blocked information sharing and strenuously argued the new rules would compromise patient privacy.)
Meanwhile, many doctors are gobsmacked and flummoxed by EHRs. The added workload of maintaining them is regularly cited as a reason for the rising rate of physician burnout. This includes an eye-opening 2017 UW–Madison study that tracked 142 family-practice doctors for three years. Those docs were found to have spent an astonishing 5.9 hours a day on EHR documentation, including time spent early in the morning or late at night catching up on their note taking.
“Something’s gone terribly wrong,” Atul Gawande, a surgeon, Harvard professor and New Yorker staff writer, summed up in 2018. “Doctors are among the most technology-avid people in society; computerization has simplified tasks in many industries. Yet somehow we’ve reached a point where people in the medical profession actively, viscerally, volubly hate their computers.”
All this suggests a hard truth of the EHR world. Epic may hands down sell the best electronic records system around, and its successes are many. But it is clear even the best EHRs are imperfect products whose flaws typify the bloat of American health care. Might there be an opening for a better EHR?
The cruel irony is that the root EHR problem may be the $36 billion subsidy itself.
Kay Plantes, a San Diego business consultant with Madison ties, thinks the subsidies were premature because the EHR technology hadn’t been worked out. “A whole lot of money was thrown at something that turned out to be not well-designed for its ultimate use — helping clinicians improve health care,” she says.
Other observers, including Redox’s Skievaski, say the hospital systems and clinics hadn’t yet reached the point where they felt it was in their best interests to cooperate with one another. But because the feds were offering the carrot of subsidization and eventually the stick of reduced Medicare and Medicaid reimbursements if they didn’t adopt electronic health records, they took the money without coming to a common ground on data sharing. Nor did the feds condition the subsidies on accepting as a core principle the free-flowing exchange of data, Skievaski adds.
Other industries — including banking, energy and cable TV — saw rival companies voluntarily accepting consensus standards for easy data access and exchange because they felt it was good for business and good for the customer. This was not the health care experience.
Healthcare IT Today’s John Lynn doesn’t blame Faulkner. “She did exactly what her clients wanted,” he says. “What client in their right mind wants to be interoperable with the competitor across the street? You’re essentially saying ‘Hey, Domino’s, will you share your client list with Pizza Hut?’ I think it’s unfortunate. Because of that thinking, the health care system as a whole is suffering.”
Lynn pauses for a moment and carefully adds, “I wish she could understand that it’s OK to be open and interoperable. And that you can do that in a way that is respectful to your client and the patient. And that the whole health care system benefits if you do.”
Plantes says Epic needs to see itself less as a software company handling health care data and more as an analytics and services company parsing that data with artificial-intelligence tools to improve medical diagnosis and treatment. That’s where she says the benefits are emerging in medical IT.
“To me the big question is how rapidly can Epic pivot to where the innovations are headed?” She argues Epic should take a lesson from Microsoft and Apple, which both found new life (and billions and billions of dollars of new revenue) by encouraging an ecosystem of vendors and software developers to cluster around, respectively, iconic Apple hardware and iconic Microsoft software.
“They viewed their partners as a real critical part of their mission,” Plantes says, while insular Epic, with few exceptions, holds mostly to a “not invented here” bias against partnering.
Plantes is not alone in arguing that Epic needs to play well with others to stay successful. But here’s the thing: I did not speak to a single health care source who felt Epic’s EHR dominance was in danger now or in the immediate future or even 10 years from now.
Epic’s bond with its clients is just too strong. And even if there are unhappy campers, dumping Epic would mean repudiating a huge investment. The Kaiser Permanente consortium spent a reported $4 billion implementing Epic’s software. The Mayo Clinic got in for $1.5 billion. The Duke University Health System for $700 million. Eight- and nine-figure acquisition fees are common for Epic clients.
How do you walk away from that? Especially when no other EHR vendor offers a major hospital “50 different modules for 50 different departments” as good as Epic’s, as Bluetree’s Schwach told me.
Well, it could happen if you follow John Neis’ worried thinking: Failure is an option.
Neis, who has been doing early-stage health care investing since the mid-1980s, quietly argues that Epic is not invulnerable. He says the core problem remains: EHRs are an imperfect solution. Doctors find them “soul crushing.” This dysfunction haunts health care.
“The cost of leaving Epic for something else is enormous,” Neis acknowledges. But “switching does happen.” And sometimes outright revolutions happen in technology, too. Seared in Neis’ memory is a long-ago conversation in Rochester, New York, with a clueless Kodak executive who confidently told him that digital photography would never replace film.
Neis argues that a tech company with unlimited resources could blow up the existing EHR model and build a far better one. He feels “the Three As” — Amazon, Apple and Alphabet’s Google, all well practiced in disrupting entrenched industries — are the most likely Epic challengers.
Could they afford to spend a billion or two devising a “leapfrog” EHR that both pleases doctors and improves their diagnostic skills with data-crunched insights? We both laugh at the absurdity of the question; $2 billion is coffee money for the tech giants.
“The challengers would need to spend serious money,” he says. “It can’t be just for some incremental improvement. It has to be a huge leap forward in both data analysis to help guide the physician to the right decisions and secondly to greatly improve the software’s interface with the physician.”
At this point, Neis offers — practically in a stage whisper over the phone — an unexpected fourth candidate for disrupting the existing EHR hegemony: the Epic team itself. No one is better situated to lead the transformation, he says. They know the customer better than anybody. They understand what the problems are. They get how complex the solution needs to be. And because Epic is private, it doesn’t have to worry about Wall Street freaking out over a bad quarter or two.
Neis’ advice: “Epic should figure out the transformation before someone else does.”
Will the post-Faulkner Epic be agile enough to reimagine its business?
That’s the cosmic question. Northwestern’s Jennifer Pendergast, who directs the John L. Ward Center for Family Enterprises at Kellogg School of Management, knows little about Epic’s operation but is very familiar with strong-willed founders like Faulkner.
“Are they kidding themselves to think they can control the future from the grave? Yes. Often to great detriment,” she says. “The goal is to be flexible, resilient, to be able to pivot given the current environment. What you want is an organization that has the capacity to think and adjust on its own.”
As for an organization that is tightly fit to its market, Pendergast says it “will be really successful until the business environment changes. And then you’ve got a problem.”
Epic’s managers may face that ultimate test sooner than later. COVID-19 and Epic’s resistance to remote working has brought the day of reckoning closer. To keep the company successful and prosperous may require them to break the very Epic commandments and principles that Faulkner has tried to enshrine in stone.
Will they have the courage and flexibility to do this?