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The Overdose – When EHRs Go Wrong

Posted on March 30, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

We’re getting more and more stories coming out about the impact for bad that an EHR can have in medicine. Most of them have been anecdotal stories like The Old Man and the Doctor Fable and Please Choose One. However, today I came across one that talked about an overdose due to an error in the use of EHR. Here’s a summary of the discovery:

Levitt’s supervising nurse was stumped, too, so they summoned the chief resident in pediatrics, who was on call that night. When the physician arrived in the room, he spoke to and examined the patient, who was anxious, mildly confused, and still complaining of being “numb all over.”

At first, he was perplexed. But then he noticed something that stopped him cold. Six hours earlier, Levitt had given the patient not one Septra pill—a tried-and-true antibiotic used principally for urinary and skin infections — but 38½ of them.

Levitt recalls that moment as the worst of her life. “Wait, look at this Septra dose,” the resident said to her. “This is a huge dose. Oh my God, did you give this dose?”

“Oh my God,” she said. “I did.”

If you read the whole article linked above, you’ll discover that the issue happened when entering the dosage for a drug into the Epic EHR system at UCSF. I’m not here to point fingers since every case is unique and you could argue forever about whether it’s the software’s responsibility to do something or whether the person using the software is responsible for understanding how the software works. I think that’s a discussion that goes nowhere since the right answer is that both can do better.

These types of stories are heartbreaking. They even cause some to question whether we should be going electronic at all. I’m reminded of a time I was considering working at a company that did expert witness testimony for cars. One of their hypothesis was that the computers that are now found in cars will usually save people’s lives. However, in a few cases they’re going to do something wrong and someone is going to lose their life. I think that’s where we’re at with EHR software. It’s not perfect and maybe never will be, but does it save more lives than it kills?

That’s a tough question that some people don’t want to face, but we’re going to face it whether we acknowledge the question or not. Personally, I think the answer to that question is that we do save more lives with an EHR than we damage. In the case above, there were still a lot of humans involved that could have verified and corrected the mistake with the EHR. They didn’t, but they could have done so and likely do with hundreds of other mistakes that occur every day. This human touch is a great counterbalance to the world of technology.

If we expanded the discussion beyond lost lives, it would be a much more challenging and complex discussion to know if EHR makes an organization more or less productive. I believe in the short term, that discussion is up for debate. However, in the long term I’m long on the benefits of EHR when it comes to productivity.

None of this should excuse us from the opportunity to learn important lessons from the story above. We need to be careful about over reliance on data in the EHR (similar to over reliance on a paper chart). We need to make our EHR smarter so that they can warn us of potential problems like the ones above. We need EHR vendors to not let known EHR problems remain unfixed. We need a solid testing plan to avoid as many of these situations as possible from ever happening in the first place.

There’s a lot of work to do still to improve EHR. This story is a tragic one which should remind us all of the important work we’re doing and why we need to work really hard to improve it now.

When Your EHR Goes Down…And It Will

Posted on March 5, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Erin McCann at Healthcare IT News wrote a recent report on a McKesson EHR outage at Rideout Health after an HVAC unit burned out. In the article she also talks about the $1 billion (I love that she added the price tag) Epic EHR outage that occurred in August 2013 at Sutter Health and lasted an entire day. Plus, she mentions the IT network failure at Martin Health System in January 2014 and had their Epic EHR down for 2 days. I’m sure there are many more that were shorter or just weren’t reported by news outlets.

When I think about EHR downtime I’m reminded of the Titanic. You can invest all you want in the “unsinkable” EHR implementation and unexpected downtime will still occur. Yes, much like the Titanic that everyone thought was totally unsinkable, it now lies at the bottom of the ocean as a testament to nature’s ability to sink anything. That includes causing your EHR to go down.

Let’s say your EHR is able to have 99.9% uptime. That would feel pretty good wouldn’t it. Well, that turns out to be 8 hours 45 minutes and 57 seconds over the year. That’s still a full working day of downtime. If you expand to 99.99% downtime, that’s still 52.56 minutes of downtime. At 99.999 (Five Nines as they say in the industry) of downtime is 5.39 minutes of downtime.

The challenge is that with every 9 you add to your reliability and uptime requirements the costs increase exponentially. They don’t increase linearly, but exponentially. Try getting that exponential cost curve approved by your hospital. It’s not going to happen.

Another way to look at this is to consider tech powerhouses like Google. They have some of the highest quality engineers in the world and pay them a lot more than you’re paying your hospital tech staff. Even with all of that investment and expertise, they still go down. So, why would we think that our hospital EHR could do better than Google?

One way many organizations try to get a Google like uptime in their organizations is to use an outside data center. Many of these data centers are able to implement and invest in a lot of areas a hospital could never afford to invest in. Of course, these data centers only provide a few layers of the technology stack. So, they can minimize downtime for some things, but not all.

The real solution is to make sure your organization has a plan for when downtime occurs. Yes, this basically means you assume that your EHR will go down and what will you do? This was my first hand experience. At one point the EHR that I implemented went down. The initial reaction was fear and shock as people asked the question, “What do we do?” However, thanks to a strong leader, she pulled out our previously created plan for when the EHR went down. Having that plan and a strong leader who reminded people of the plan calmed everyone down completely. It still wasn’t fun to have the EMR down, but it was definitely manageable.

What have you done to prepare for EHR downtime? Do you have a plan in place? Have you had the experience of having your EHR down? What was it like? Are you afraid of what will happen in your hospital when your EHR goes down?

RNs are Choosing Where to Work Based on Hospital EHR

Posted on February 27, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I came across this tweet and it made me stop and realize how important the selection and more important the implementation of your EHR will be for your organization. In many areas there’s already a nurse shortage, so it would become even more of an issue if your hospital comes to be known as the hospital with the cumbersome EHR.

Here’s some insight into the survey results from the article linked above:

79% of job seeking registered nurses reported that the reputation of the hospital’s EHR system is a top three consideration in their choice of where they will work. Nurses in the 22 largest metropolitan statistical areas are most satisfied with the usability of Cerner, McKesson, NextGen and Epic Systems. Those EHRs receiving the lowest satisfaction scores by nurses include Meditech, Allscripts, eClinicalWorks and HCare.

The article did also quote someone as saying that a well done EHR implementation can be a recruiting benefit. So, like most things it’s a double edge sword. A great EHR can be a benefit to you when recruiting nurses to your organization, but a poorly done, complex EHR could drive nurses away.

I’m pretty sure this side affect wasn’t discussed when evaluating how to implement the EHR and what kind of resources to commit to ensuring a successful and well done EHR implementation. They’re paying the price now.

Department of Defense (DOD) and Open Source EHR

Posted on February 25, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I was intrigued by a report by the Center for New American Security that was covered in this article on HealthcareDive. In the report, they make a good case for why the Department of Defense (DOD) should select an open source EHR solution as opposed to a commercial solution. Here’s an excerpt from the article:

“I think the commercial systems are very good at what they do,” Ondra said. However, “they are not ideally designed for efficiency and enhancement of care delivery, and I think the DOD can do better with an open source system both in the near-term, and more importantly in the long-term, because of the type of innovation and creativity that can more quickly come into these systems.”

Reports like this make a pretty good case for open source. Plus, I love that it also pointed out that commercial EHR vendors were built on the back of the fee for service model which doesn’t matter to the DOD. It was also interesting to think about the DOD’s selection of an open source EHR system as an investment in other hospitals since the money they spend on an open source EHR could help to catalyze the ongoing development of a free open source EHR solution.

While these arguments make a lot of sense, it seems that the DOD has decided not to go with an open source EHR solution and instead is opting for a commercial alternative. In this article (Thanks Paul) the DOD has narrowed the list of contenders for the $11 Billion DOD EHR contract (DHMSM) to just: CSC/HP/Allscripts, Leidos/Accenture/Cerner, and IBM/Epic who “fall within the competitive range.” They reported that PwC/Google/GDIT/DSS/Medsphere and Intersystems did not fall within the competitive range.

I’ll be interested to hear Medsphere’s take on this since every report I’ve ever read has Medsphere and their open source Vista solution as much less expensive than the commercial alternatives (Epic, Cerner, Eclipsys). So, I can’t imagine that the Medsphere bid was so much more than the others. Unless the consultants are charging through the nose for it. Or maybe the open source Vista option wasn’t “in the competitive range” because it was too cheap. Wouldn’t that be hilarious to consider. Hopefully the government isn’t that stupid, but…

I don’t claim to have any clue on how these $11 billion government contract bids work. I’m just a casual observer from the sideline. It seems like 3 companies remain in the ring. I guess the Google juice wasn’t enough for the PwC/Medsphere bid.

The Epic App Store (Epic App Exchange) Is Coming

Posted on February 19, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

The Wisconsin State Journal is reporting that Epic is working on the Epic App Store which will be called the Epic App Exchange. I guess the news was mentioned by Mark Bakken, co-founder and former chief executive of Nordic Consulting, at a Wisconsin Innovation Network event and confirmed by Shawn Kiesau, Epic spokesman. Here’s a quote from the article:

Bakken said the app store will launch in a few weeks and it will “open the floodgates” for all sorts of companies to develop and market their apps, especially those in the Madison area populated by former Epic employees.

“We think Epic is big now? This will cement their long-term legacy. It’s exactly the right thing to do,” Bakken said later in an interview.

Bakken has obviously drunk the Epic Kool Aid having created a very large Epic consulting firm in Madison and he’s now creating an investment fund called HealthX Ventures that’s focused on healthcare IT startups with many of them created by former Epic employees. He is right that an Epic app store with a robust API could be an awesome opportunity for Epic and entrepreneurs.

What’s not clear to me from this initial news is how open the Epic app store will really be. If it’s like their previous Epic API, it wasn’t much to write about. It didn’t allow an app to integrate deeply with the Epic system. Will we once again be disappointed by the Epic App Store, or will they start to really open up Epic to entrepreneurs who want to build applications on top of their systems?

My gut tells me that the former is more likely. This actually puts people like Bakken with deep relationships with Epic at a real advantage. My bet is that Epic will only work with companies and organizations that they trust and so these already existing relationships could become even more valuable. While it’s true that Epic should be careful with how they work with external companies that want to leverage the new Epic app store, there are ways they can protect their customers and patient data while still opening up their application to entrepreneurs of every kind. We’ll see if I’m wrong about this. Maybe they will really open things up, but I’m skeptical that they’ll be able to overcome their fear (unfounded as it may be).

In the article linked above, Bakken is quoted as saying that “he expects the first apps to come from Epic’s customer.” This would confirm my prediction above that Epic will be afraid to really open up its platform to entrepreneurs and instead will focus the app store on their closed customer ecosystem. Even the name “Epic App Exchange” hints at this being the case. They want their customers to exchange apps. They aren’t looking to create a true app store where entrepreneurs can innovate on top of Epic’s base.

Of course, since Epic doesn’t like to work with the media very much, it’s hard to know what the Epic App Store will really look like when it’s launched. This is a step in the right direction for Epic. I just still don’t think Epic understands the opportunity that they have to really improve healthcare and solidify themselves as the go to leader in healthcare IT. I’ll continue to hope I’m wrong and Epic will blow us away with the official announcement and details of a really open app store and API.

BIDMC’s Internal EHR and A Possible Epic Future

Posted on February 11, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

One of the surprising reactions for me in the announcement of Athenahealth’s acquisition of Beth Israel Deaconess Medical Center’s (BIDMC) in house webOMR platform was by John Halamka. As I mention in the linked article, it really isn’t a pure software acquisition as much as it is Athenahealth going to school to learn about the inpatient EHR space. However, John Halamka’s reaction to this announcement is really interesting.

As I read through all of the coverage of the announcement, John Halamka seems to have shifted gears from their current in house EHR approach to now considering a switch to some other external EHR vendor. This is very interesting given this blog post by John Halamka back in 2013. Here’s an excerpt from it:

Beth Israel Deaconess builds and buys systems. I continue to believe that clinicians building core components of EHRs for clinicians using a cloud-hosted, thin client, mobile friendly, highly interoperable approach offers lower cost, faster innovation, and strategic advantage to BIDMC. We may be the last shop in healthcare building our own software and it’s one of those unique aspects of our culture that makes BIDMC so appealing.

The next few years will be interesting to watch. Will a competitor to Epic emerge with agile, cloud hosted, thin client features such as Athenahealth? Will Epic’s total cost of ownership become an issue for struggling hospitals? Will the fact that Epic uses Visual Basic and has been slow to adopt mobile and web-based approaches provide to be a liability?

Or alternatively, will BIDMC and Children’s hospital be the last academic medical centers in Eastern Massachusetts that have not replaced their entire application suite with Epic?

Based on John Halamka’s comments it seems that his belief might have changed or at least he’s considering the option that an in house system is not the right approach moving forward. No doubt Athenahealth is hoping that they’ll delay the decision a few years so they have a chance to compete for BIDMC’s business.

If you look at the rest of the blog post linked above, Halamka was making the case for Epic back in 2013. I think that clearly makes Epic the front runner for the BIDMC business at least from Halamka’s perspective. We’ll see how that plays out over time.

It seems like we’re nearing the end of the in house EHR hospital. Are there any others that still remain?

Will Cerner Let Mayo Clinic Move to Epic Easily?

Posted on February 9, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

As most regular readers know, we don’t try to get into the rat race of breaking news on things like EHR selection, the latest meaningful use, or whatever else might be time sensitive healthcare news. Sure, every once in a while we’ll report something we haven’t seen or heard other places, but we’re more interested in the macro trends and the broader insight of what various announcements mean. We don’t want to report on something happening, but instead want to tell you why something that happened is important.

A great example of this is Mayo Clinic’s decision to go with Epic and leave behind Cerner, GE, and other systems. There’s a good interview with Mayo Clinic CEO, Cris Ross, that talks about Mayo’s decision to go with Epic. As he says in the interview, GE Centricity wasn’t part of their future plans, and so they were really deciding between Epic and Cerner. Sad to see that Vista wasn’t even part of their consideration (at least it seems).

Based on Cris Ross’ comments, he commented that he liked Epic’s revenue cycle management and patient engagement options better than Cerner. Although, my guess is that they liked Epic’s ambulatory better than Cerner as well since they were going away from GE Centricity. Cris Ross’s double speak is interesting though:

As we looked at what met our needs, across all of our practices, around revenue cycle and our interests around patient engagement and so on, although it was a difficult choice, in the end it was a pretty clear choice that Epic was a better fit.

Either it was a difficult choice or it was a pretty clear choice. I think what Cris Ross is really saying is that they’d already decided to go with Epic and so it was a clear choice for them, but I better at least throw a dog bone to Cerner and say it was a hard choice. Reminds me of the judges on the voice that have to choose between two of their artists. You know the producers told them to make it sound like it’s a hard choice even if it’s an easy one.

Turns out in Mayo’s case they probably need to act like it was a really hard choice and be kind to Cerner. Mayo has been a Cerner customer for a long time and the last thing they want to do is to anger Cerner. Cerner still holds a lot of Mayo’s data that Mayo will want to get out of the Cerner system as part of the move to Epic.

I’ll be interested to watch this transition. Will Cerner be nice and let Mayo and their EHR data go easily? Same for GE Centricity. I’ve heard of hundreds of EHR switches and many of them have a really challenging time getting their data from their previous EHR vendor. Some choose to make it expensive. Others choose to not cooperate at all. Given Mayo’s stature and the switch from Pepsi to Coke (Cerner to Epic, but I’m not sure which is Pepsi and which is Coke), I’ll be interested to see if Cerner lets them go without any issues.

I can’t recall many moves between Epic and Cerner and vice versa. Although, we can be sure that this is a preview of coming attractions. It will be interesting to see how each company handles these types of switches. What they do now will likely lay the groundwork for future EHR switching.

IBM and Epic Prep for Multi Billion Dollar DoD EHR Contract

Posted on January 12, 2015 I Written By

In this recent Nextgov article, they talk about what Team IBM/Epic are doing to prepare for the massive bid:

On Wednesday, IBM and Epic raised the bar in their bidding strategy, announcing the formation of an advisory group of leading experts in large, successful EHR integrations to advise the companies on how to manage the overhaul — if they should win the contract, of course.

The advisory group’s creation was included as part of IBM and Epic’s bid package, according to Andy Maner, managing partner for IBM’s federal practice.

In a press briefing at IBM’s Washington, D.C., offices, Maner emphasized the importance of soliciting advice and insight from the group. Members of the advisory board include health care organizations, such as the American Medical Informatics Association, Duke University Health System and School of Medicine, Mercy Health, Sentara Healthcare and the Yale-New Haven Hospital.

Add this new advisory group to the report that Epic and IBM set up a DoD hardened Epic implementation environment and you can see how seriously they’re taking their bid. Here’s a short quote from that report:

Epic President Carl Dvorak explained the early move will also help test the performance of an Epic system on a data center and network that meets Defense Information Systems Agency guidelines for security. An IBM spokesperson told FCW that testing on the Epic system has been ongoing since November 2014.

As we noted in our last article, 2015’s going to be an exciting year for EHR as this $11+ billion EHR contract gets handed out. What do you think of Team IBM/Epic’s chances?

A Turning Point? Wearables Could Save 1.3M Lives by 2020

Posted on December 22, 2014 I Written By

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

For years, wearable health bands have been expensive toys useful almost exclusively to fit people who wanted to get fitter. On their own, wearables may be chic, sophisticated and even produce medically relevant information for the user, but they haven’t been integrated into practical care strategies for other populations.

And with good reason. For one thing, doctors don’t need to know whether an otherwise-healthy patient took 10,000 steps during a run, what their heart rate was on Thursdays in June or even what their pulse ox reading was if they’re not wheezy asthmatics. Just as importantly, today’s EMRs don’t allow for importing and analyzing this data even if it is important for that particular patient.

But as the banners at last week’s mHealth Summit pointed out, we’re headed for the era of the mHealth ecosystem, a world were all the various pieces needed to make patient generated data relevant are in place. That means good things for the future health of all patients, not just fitness nuts.  In fact, a Swiss analyst firm is predicting that smart wearable devices will save 1.3 million lives by 2020, largely through reductions in mortality to in-hospital use of such devices, according to mobihealthnews.

New research from Switzerland-based Soreon Research argues that smart wearables, connected directly with smart devices, projects that using wearables for in-hospital monitoring will probably save about 700,000 lives of the 1.3 million it expects to see preserved by 2020. Even better, wearables can then take the modern outside the hospital. “New wearable technology can easily extend monitoring functions beyond the intensive care unit and alert medical professionals to any follow on medical problems a patient may develop,” according to Soreon Research Director Pascal Koenig.

Not surprisingly, given their focus on monitoring aerobic activities, Soreon projects that wearables can be particularly helpful in avoiding cardiovascular disease and obesity. The firm believes that monitoring patients with wearables could prevent 230,000 deaths due to cardiovascular diseases, and reduce obesity related deaths by 150,000.

And that’s just a taste of how omnipresent wearables use may be within a few years. In fact, Soreon believes that patients with chronic conditions will help push up the smart wearables market from $2 billion today to $41 billion, or more than 1000% growth. That’s a pretty staggering growth rate regardless of how you look at it, but particularly given that at the moment, clinical use of smart wearables is largely in the pilot stage.

What few if any pundits are discussing — notably, as I see it — is what software tools hospitals will use to crunch this flood of data that will wash it on top of the astonishing volume of data EMRs are already producing.

True, at the mHealth Summit there were vendors pitching dashboards for just this purpose, who argued that their tools would allow healthcare organizations to manage populations via wearable. And of course tools like Apple HealthKit and Microsoft Health hope to serve as middlemen who can get the job done.

These solutions will definitely offer some value to providers. Still, I’d argue that wearables will not make a huge impact on clinical outcomes until the day what they produce can be managed efficiently within the EMR environment a provider uses, and I don’t see players like Epic and Cerner making big moves in this direction. When the mHealth ecosystem comes together it’s likely to produce everything analysts predict and more, but bringing things together may take much longer than they expect.

Healthcare Interoperability – Learning From Proprietary PC History

Posted on December 16, 2014 I Written By

Interoperability; Some vendors have the unmitigated gall to try and keep their systems proprietary. When they refuse to make code or training available to others, competition will have difficulty achieving interoperability and customers will not be able to move too far from the vendor and their own profitability is secured. Competition is greatly reduced.  Capitalism at its finest.

A long, long time ago in a land far away, 4 vendors in the minicomputer and PC markets attempted to do just about the same thing. Wang, Data General and Digital Equipment were almost totally proprietary. Interoperability was little more than a dream. Proprietary would secure success.  The fourth company was the leader in the PC world. They also were not able to communicate with competitors and vice versa. For years, IBM compatible meant the difference between success and failure. Why? Try profit. If you control a market and can keep others away, profits remain high.   After a time, as with IBM there will come a time that giving up the proprietary nature of the product will cause an increase in sales and profits.

Throughout the 80’s and 90’s IBM’s competitors and some large users complained bitterly about all four company’s proprietary nature. The 3 minicomputer companies “bet the farm” that they could succeed by being proprietary. IBM did the same. The rest is history. One won and three lost.

Epic is in the same boat as those four. Being proprietary is increasing their profitability currently.  As time progresses will Epic decide that the time is right to allow the competition access to their product and code and, like IBM, will they do it at the right time to remain the market leader.  Any bets?