The Frontier

Epic Systems, located in Verona, Wisconsin, provides electronic health records for over 80% of Americans and operates in 16 countries. It is the largest player in its industry, making software for many major U.S. healthcare systems.

Judy Faulkner, Epic's founder and CEO since 1979, describes her role as ensuring company success through product accountability, client happiness, and strategic decisions, viewing her job as knowing 'who knows the answer.'

Faulkner, an introverted 'techie,' generally avoids interviews due to their time-consuming nature and potential for missteps. Her leadership style is rooted in a coder's mindset, focusing on parameters and error resolution.

Bob Wachter credits Epic's market dominance to its integrated software solution, which avoids combining disparate tools from different companies. This approach helps manage the complexity of medicine effectively.

Epic operates an IT organization with approximately 15,000 employees and its 'MyChart' patient portal has been available for about 25 years. Faulkner notes many users are unaware Epic develops MyChart.

Epic is an outlier for avoiding private equity or venture capital funding, never having been sued by a customer in its nearly 50-year history. The company has only lost one customer, who later returned.

Faulkner's mother, Del Greenfield, was a peace activist who shared a 1985 Nobel Peace Prize for her work with Physicians for Social Responsibility, and charged Faulkner with making the world a better place.

Faulkner received a master's in computer science in 1979 from the University of Wisconsin, where she took one of the first classes in computers in medicine. Her early work focused on automating call schedules and patient information tracking.

Faulkner notes that healthcare accounts for 18% of U.S. GDP and believes Epic's single, integrated software system helps reduce costs by consolidating many separate applications. She views healthcare professionals as highly ethical.

Epic developed 'Care Everywhere' around 2007 to enable information sharing between healthcare providers, a response to a patient death caused by a lack of shared medical history. This system helps prevent similar incidents by ensuring critical data is accessible.

Epic faces antitrust lawsuits from the Texas Attorney General and Particle Health, which Faulkner addresses by explaining the complexity and cost of integrating with numerous third-party systems due to differing designs and safety concerns.

Faulkner states Epic's annual revenues, last seen at $5.8 billion, are not driven by profit maximization; instead, the company prioritizes using sufficient revenue to operate successfully and supporting customer needs over high profits.

Epic typically spends 30-35% of its annual revenue on research and development, a figure driven by needs like AI integration and web migration, rather than strict budget goals. The company does not use traditional budgets.

Epic operates by 'Ten Commandments' posted on campus, including 'do not go public' and 'do not acquire or be acquired,' which Faulkner states have never been close to broken. She believes public shareholders prioritize equity returns over company value.

Faulkner has structured her succession plan so her Epic stock's value goes to the 'Roots and Wings' charitable foundation, with voting rights controlled by a Purpose Trust of family and staff. This trust is legally bound to prevent the company from going public or being acquired.

Epic's international expansion into 16 countries is client-driven, with potential customers initiating contact. Epic rejects clients, both domestically and internationally, if it believes they are too small or lack the resources to successfully implement the software.

Epic aims to expand access for rural hospitals by encouraging large state systems to extend coverage, having states purchase software for broader reach, or by assisting rural groups in forming collective purchasing alliances.

Faulkner, at 82, has no target retirement date and hopes to continue working, with her succession plan ensuring the company's core values endure. Her one recommendation for future leadership is that the company's hold music remain classical.

Epic's campus environment is designed to be 'whimsical' and friendly, contributing to employee happiness and retention. The company receives around 350,000 job applications annually, reflecting its desirability as an employer.

Seth Howard, Epic's EVP of R&D, explains the 'Discovery' network facilitates clinical trials by connecting life science organizations with eligible patients beyond academic medical centers. This democratizes access for patients in community and rural hospitals.

Faulkner worries about the future of the country, education, and healthcare affordability. She acknowledges AI's potential in healthcare, particularly in predicting diseases and helping physicians, but also expresses concern about it being 'gamed.'

Epic uses AI for sepsis detection, with one hospital reducing septic patients from 2.5% to 0% and saving over 100 lives using the system. Epic's AI also provides a 'diagnosis checker' to alert physicians to rare diagnoses, as roughly 10% of diagnoses are wrong.

Epic's 'best care choices for my patient' AI feature provides clinicians and patients with data on medication effectiveness, side effects, and costs for similar cases. This supports informed decision-making without dictating treatment.

Dubner notes that many physicians perceive Epic's software as 'sludgy' and complex for daily use, despite the industry's overall preference for it. Faulkner attributes some efficiency issues to government requirements, like the High Tech Act, which mandated doctors type notes.

Faulkner denies inhibiting independent app development, stating Epic offers more APIs than other vendors. She clarifies that third-party apps need permission from the healthcare organization, not Epic, to access patient data.

Eric Adams, as Mayor of New York City, posted a job listing in Fall 2022 for a "Director of Rodent Mitigation" with qualifications like being "highly motivated and somewhat bloodthirsty" for "wholesale slaughter."

Kathy Karate, New York City's former "Rat Tsar," states that rat mitigation involves understanding the animals' needs for shelter and food, which are often provided by neglected urban spaces like overgrown areas or accessible waste.

Karate indicates that sanitation is the primary control for any pest, explaining that her previous role in the Department of Education focused on waste management in schools to reduce food sources for rats.

The exact size of New York City's rat population is unquantifiable, according to Kathy Karate, who dismisses specific estimates as futile given the constantly changing nature of their numbers.

Rats are described as commensal, meaning they thrive in close proximity to humans by utilizing resources available in urban environments, showcasing remarkable adaptability and intelligence.

Bethany Brookshire, author of *Pests*, highlights that the historical perception of rats as disgusting and disease-carrying is relatively recent, evolving from earlier dislikes based purely on food supply competition.

Niels Christian Stenseth and colleagues published a 2018 paper in *PNAS* challenging the traditional view that rats and fleas caused the Black Death, suggesting human ectoparasites like lice were more likely vectors.

The Black Death, caused by the *Yersinia pestis* bacterium, killed half of Europe's population in one to two years and spreads via fleas transmitting bacteria through bites or human-to-human by droplets and ectoparasites.

Ed Glazer, an economist, suggests that while rats present negative externalities like property damage and potential disease vectors, their impact on urban density is minor, arguing against complete eradication as a fetish.

Kathy Karate notes the economic impact of rats includes property damage from chewing wires and foundations, food contamination, and mental health issues like stress and anxiety among residents.

Public health risks from rats include leptospirosis, with 24 diagnosed cases in New York City in 2023, and the potential for novel viruses they carry to mutate and jump to human hosts.

Pigeons, once essential for communication and agriculture, fell from public favor to become "rats with wings" as their utilitarian roles were replaced by modern technology and chemical fertilizers.

Bethany Brookshire highlights cultural differences in rat perception, citing the Karnimata Temple in Deshnoge, India, where 25,000 sacred rats are considered reincarnations of people and receive lavish care.

Brookshire argues that human hatred for pests stems from our expectation that animals will disappear from developed spaces; their continued success, especially thriving on human-valued resources, feels like our failure.

New York City's Department of Sanitation reported a 20% year-over-year decline in rat sightings, and Mayor Zoran Mamdani plans citywide trash containerization by the end of 2031 to continue mitigation efforts.