Epic系统（MyChart）

尽管我们最初将这些事物称为EMR（电子病历），但开始将EMR视为整个系统的一个功能组成部分是相当合理的。是的。

It's quite reasonable even though we refer to these things as EMRs to start thinking about EMR as a feature for a constituency of the whole system. Yes.

于是在2003年2月，凯撒医疗发布了一份RFP（征求建议书），寻求一个全新的——再次强调是所谓的——EHR（电子健康记录）系统，但实际上是为整个凯撒打造的新神经系统。没错。最终Epic赢得了这笔交易。

So in 02/2003, Kaiser puts out an RFP for a new, again, quote, unquote, EHR, but really new nervous system Yep. For all of Kaiser, And Epic wins the deal.

而Epic当时还是家小公司。就在几年前，他们只是个年收入5000万美元的企业。

And Epic was a little company. Just a few years before, they were a $50,000,000 company.

是的。但在签下凯撒后，他们的年收入飙升至1.62亿美元。堪称蜕变式增长——几乎是一夜之间让收入翻倍还不止。

Yes. And after they signed Kaiser, they go to a 162,000,000 in annual revenue. So transformative. Probably more than doubled their revenue overnight.

没错。有意思的是，我们聊聊价格细节吧。媒体报道的 headline数字是40亿美元——他们称之为为期三年的40亿美元项目，其中Epic的部分约4亿美元。当然不是一次性支付，这类项目的运作模式是前期需要大量资金投入实施，然后是持续的软件使用许可费，我认为最终会过渡到订阅模式。

Yep. Interestingly, let's talk prices for a second. The headline number, as everyone reports it, is a 4,000,000,000 deal. They call it a $4,000,000,000 three year project, and that Epic's portion is around 400,000,000. Of course, not all in one year, but the way these things work is there's a big implementation that costs a bunch of money up front, and then there's the ongoing license that I think eventually would transition to subscription.

不过现阶段还是软件使用许可。看这些媒体报道很有趣，因为40亿美元这个数字不仅涵盖多年合约和实施成本，还把医院员工投入的工作量、以及整个医疗系统医生适应新软件可能损失的生产力都计算进去了。

But at this point, it's licensing to use the software. It's just funny to see these headlines because the 4,000,000,000 number, not only they capture many years of the deal and the implementation, but they also roll in their the headcount of the hospital employees that have to do the work, and they roll in their the potential lost productivity from all doctors across the health system who have to sort of ramp on the new software.

顺便说句，这些确实是实际经济影响。但Epic可没从中拿到40亿美元。

Which is a real economic impact, by the way. For sure. But it's not like Epic got $4,000,000,000 out of this.

确实。我总忍不住发笑，因为这些数字个个看起来都大得惊人——数十亿美元项目。哦，即便是小型医疗系统也是3亿美元项目，但最终Epic实际获得的远没这么多。不过这就是行业约定俗成的交易规模表述方式。

No. And I always chuckle because every single one of these numbers looks huge. Multi billion dollar. Oh, even if it's small health system, $300,000,000 project, and it ends up resulting in nowhere near that much money to Epic, but this is how the industry has decided to talk about the size of these deals.

是啊，挺有意思的。我们或许该开始讨论收购规模时也把...

Yeah. It's funny. We should start talking about the size of acquired and, you know, like

第四层第五层的间接影响都算上。

Fourth and fifth degree, tertiary impacts.

我们是一家价值十亿美元的企业。

We are a billion dollar business.

想想我们的客户在获取听众时所做的所有业务。但你说得对，这实际上很公平。如果凯撒医疗要花几年时间更换他们的中枢神经系统，这将对他们产生40亿美元的净影响。

Just think about all the business that our customers do when acquired listeners. But to your point, it is actually fair. If Kaiser is gonna engage in switching their central nervous system over several years, it's going to be net $4,000,000,000 of impact to them.

是的。这件事的发展过程非常戏剧性。当时，凯撒医疗的两个主要重心是北加州和南加州，它们几乎像是凯撒旗下的两家独立公司。有不同的系统，各自的电子病历，不同的管理层。当然，它们彼此交流，属于同一个母公司。

Yes. So the story of how this goes down is wild. At the time, Kaiser's two main centers of gravity were Northern California and Southern California, and they were almost like separate companies under the Kaiser umbrella. Had different systems, had their own EMRs, different management. Of course, talked to each other and part of the same parent organization.

是不是还有一个像西北分部这样的类似表亲组织？是的。像个继子一样？所以他们有，我不知道

Wasn't there like a almost like cousin organization that was Northwest? Yes. Like this stepchild? So they had I don't know

是否只有西北分部，或者他们当时可能还有其他较小的地区业务，但他们有一个位于俄勒冈州波特兰市的太平洋西北小分部。实际上，如今凯撒医疗在全国大部分地区都有大型分部。自那时以来，他们发展了很多。但这个小小的波特兰分部，他们已经开始在门诊诊所使用Epic系统。所以，甚至不是医院的住院部分，而是他们的门诊诊所。

if it was just Northwest or they had maybe some other smaller regional operations at the time, but they had a Pacific Northwest small region based in Portland, Oregon. Today, actually, Kaiser has large regions through a large part of the country. They've grown a lot since then. But this small little Portland region, they had started using Epic for their ambulatory clinics. So, like, not even inpatient stuff in the hospital, but their outpatient clinics.

当时，北加州和南加州的两大派系正在互相争斗，各自试图开发自己的专有电子病历系统，与软件顾问如埃森哲等合作。

And at the time, the Northern California and Southern California big factions were battling each other, and they're each trying to develop their own proprietary EMR systems with software consultants with, like, Accenture and stuff.

是的。曾经有一个时代，医院认为电子病历应该是他们的知识产权，他们开发并拥有对其他医院的竞争优势，因为他们的电子病历更好。我不知道当时的想法是什么，但人们想拥有自己的电子病历。

Yeah. There was this era where hospitals thought that EMRs should be their IP, that they develop and have sort of a competitive advantage over other hospitals because their EMR was better. I don't know what the thinking was, but people wanted to own their own EMRs.

我认为甚至可能有一些不切实际的幻想，比如，哦，我们要把这个商业化并卖给其他医院。这似乎不是医院应该做的核心业务。无论如何，在凯撒系统内部，医生的流动性相当高。所以如果你是凯撒太平洋西北分部的一名医生，你想搬家或你的家人必须搬到加州，你可以很容易地转到凯撒的北加州或南加州分部。所以这种情况发生了。

I think there may even have been some pipe dreams of, like, oh, we're gonna commercialize this and sell it to other hospitals. It seems like not a core competency that hospitals should be doing. Anyway, within the Kaiser system, though, there was a fairly high degree of rotatability of physicians, of doctors. So if you were a doctor in Portland with Kaiser Pacific Northwest and you wanted to move or your family had to move down to California, you could transfer pretty easily to Northern or Southern California, Kaiser. So this was happening.

随着来自西北部的医生开始来到加州，他们觉得，伙计，你们在干什么？你们花这么多钱请埃森哲和这些顾问来尝试自己开发。我们在波特兰用的这个叫Epic的东西，甚至还没在医院使用，就比你们试图构建的东西好得多。是的。所以最终，在北加州和南加州之间的这场争斗持续了一两年后，他们终于同意，好吧。

And as physicians from the Northwest started coming down to California, they feel like, man, what are you guys doing? You're spending all this money with Accenture and, you know, blah blah blah, all these consultants to try to roll your own. Like, we've got this thing called Epic up in Portland that we're not even using at the hospital, and it's way better than the stuff that you're trying to build. Yeah. So finally, after a year or two of this battle between north and south, they finally agree, alright.

停火。达成了休战协议。我们将放弃我们的竞争项目，并将这个项目外包给第三方供应商。所以他们为整个凯撒医疗的新电子病历系统发布了一份征求建议书，一个集成系统，他们选择了IBM。IBM将进来为凯撒医疗做这个40亿美元的大项目。

Ceasefire. It's come to a truce. We're gonna ditch our competing projects, and we're gonna bid this out to third party vendors. So they hold an RFP for a new EMR for all of Kaiser, one integrated system, and they pick IBM. IBM is gonna come in and do this big $4,000,000,000 project for Kaiser.

没人会因为购买IBM的产品而被解雇。我们正处于那个时代的尾声，但依然残留着那个时代的影子。

Nobody gets fired for buying IBM. We're on, like, the end of that era, but it's still little that era.

我是说，这里才2003年。这个投标甚至可能发生在2003年2月之前。IBM进场后，项目失败了。根本行不通。

I mean, it's only 2003 here. This bid might have even happened before 02/2003. So IBM comes in, and the project fails. Doesn't work.

这种情况并不罕见，尤其是想想ERP系统，你听过多少次'ERP实施失败'的故事？有些CEO在财报电话会上解释：'我们损失了数亿甚至数十亿美元，结果连系统都没换成'。这类事在医院领域也会发生。而Epic公司把全部声誉押在'我们从不实施失败'上，正是这点让他们赢得了合同。

And this is not uncommon, especially think about ERP, the number of times you've heard, oh, failed ERP implementation, and some CEOs explaining on an earnings call, yeah, we'd lost hundreds of millions or billions of dollars, and we actually didn't even switch systems. This sort of thing does happen in the hospital world too. And Epic has bet the whole company on having a reputation for we don't have failed implementations, and that wins deals.

完全正确。我认为这正是客户喜爱他们的最重要原因之一。

Totally. I mean, I think this is one of the most important reasons why their customers love them.

这期节目我们会反复强调：他们的客户爱他们。当我们说'客户'时，指的是医院CEO、CIO（首席信息官）和CFO。我们提到的客户就是这些人。当然，首席医疗官、全体医生护士和护理人员也是其中的一部分。

And we're gonna say this a bunch of times on the episode. Their customers love them. When we say customer, we mean hospital CEO, CIO, the chief information officer, and CFOs. When we refer to their customers, that's who we're talking to. Obviously, the chief medical officer and all of the physicians and nurses and care folks are a part of that.

但我的部分研究表明，真正的客户是医院管理层。

But a part of my research has revealed the customer is the hospital administration.

我怀疑这在Epic公司内部都算不上有争议的说法。他们认为客户就是医院CEO、CIO和CFO。没错。所以IBM项目失败了，或许值得再补充一句——

I doubt that's even, like, a controversial statement probably at Epic themselves. I think they consider the customer to be the CEO, CIO, and CFO of their customers. Yep. So the IBM project fails. And maybe it's worth another word on that too.

这并非对医生和医院员工没有影响。像这次IBM实施失败案例中，医院表现糟糕，对医生群体造成巨大损害。他们当时肯定苦不堪言，毕竟他们也渴望系统稳定。

It's not like this doesn't impact the physicians and the staff of the hospitals and poor performance for the hospital as is in the case of this failed IBM implementation, massive detriment to the physicians. This must have really, really sucked for them. Like, they want stability too.

医生才是医院的价值创造者，所以管理层必须让医生满意才能保住饭碗。医生凭借核心技能在组织里拥有话语权。但说到底，你去争取客户时推销对象不会是医生群体。

And the physicians provide the value at hospitals, and so therefore, you need to make the physicians happy to retain your administration job. They have the leverage in the organization because they provide the core competency. But still, you're not going in and pitching the doctors when you're going in and trying to land a customer.

你可以把医院想象成媒体公司。医生、护士和临床人员就像出镜艺人。没错，在迪士尼或环球影城这些地方，做商业决策的从来不是出镜艺人。

You could think of a hospital almost like a media company. The doctors and the nurses and the clinicians, they're the on air talent. Yeah. The on air talent are not the ones, you know, at Disney or Universal or wherever who are making the business decisions. Right.

在这种情况下，医务人员虽然参与其中，但他们并非决策者。

And in this case, the medical staff is involved, but they're not the decision maker.

没错。好吧，凯撒现在得重新招标这个项目。当时已经有足够多的波特兰医生来到加州，对Epic赞不绝口，所以他们觉得，好吧，我们该认真对待这家小公司了。

Yep. So okay. Kaiser's now gotta rebid this project. And by this point in time, enough Portland doctors had come down to California and sung Epic's praises that they're like, alright. We should take this little company seriously.

于是他们启动了RFP（提案请求），最终竞争落在Epic与其主要竞争对手Cerner之间。目前我们在这期节目里还没怎么聊过Cerner——它现在是甲骨文的一部分，稍后会详细讨论。Cerner当时规模要大得多。

So they start the RFP, and it comes down to Epic and their big main rival, Cerner. Now we haven't really talked about Cerner so far in this episode, part of Oracle today, so we will get into later. Cerner was a much bigger company.

对。有趣的是，两家公司差不多同时成立对吧？

Yep. Interestingly, started right around the same time. Right?

是啊。哇，我记得它和Epic是同一年创立的？1979年？

Yeah. Wow. I think it was started the same year as Epic. Right? 1979?

没错。由密苏里州堪萨斯城的尼尔·帕特森创立。Epic走的是不拿风投、不做收购、单一平台、永远私有化的路线，而Cerner则选择了大量收购、融资、上市、扩张规模的路线。

Yep. By Neil Patterson. By Neil Patterson in Kansas City, Missouri. Unlike Epic, which took the no venture capital, no acquisitions, single platform, stay private forever route. Cerner took the lots of acquisitions, raise capital, go public, get big route.

那条路本来也可能成功的。

Which could have worked too.

也确实成功过。

It did work too.

确实成功了很多年。

It did work for a long time.

是的。那时候Cerner已经是年收入近十亿美元的企业了。他们是上市公司，规模大得多，业务也国际化等等。所以RFP最终就在这两家公司之间展开。

Yep. At this point in time, Cerner is almost a billion dollar a year revenue business. They're a public company, way, way, way bigger. They're international, etcetera. So the RFP comes down to the two of them.

但值得一提的是，在被甲骨文收购之前，它是由24家不同公司合并而成的。给它贴上个漂亮的小标签，称之为Cerner，但一路上兼并了许多公司。

But it's worth saying before they were acquired by Oracle was a merger of 24 different companies. Put a nice little rapper on it and call it Cerner, but a lot of companies along the way.

是的。可以说与朱迪选择的道路不同。是的。但这并非贬低它。在当时，这确实是一款极具竞争力的好产品。

Yes. A different path than the one Judy took, let's say. Yes. But that's not to knock it. It is, and especially back then, was a good, really competitive product.

2003年对凯撒医疗来说，显然会选择Cerner。他们确实曾试图选择Cerner。据说有次他们同时接触了Cerner和Epic两家公司，表示：Cerner，我们想在医院住院系统上采用你们的方案，因为这是你们的强项，也是最重要的部分。

The obvious choice for Kaiser here in 2003 would have been go with Cerner. And they actually try to go with Cerner. So supposedly, at one point, they come to both companies, to Cerner and Epic, and they say, look. Cerner, we wanna go with you for inpatient in the hospital since that's your bread and butter. This is the most important thing.

这是大生意。我们信任你们。你们历史悠久。而Epic，你们现在虽然有住院系统，但2001年2月才刚推出。

This is the big business. We trust you. You've been around forever. And Epic, hey. You've got inpatient now, but you only just launched that in 02/2001.

你们在这方面还是新手。你们擅长门诊业务，在波特兰为我们做得很好。我们想折中处理：门诊诊所使用Epic系统，住院诊所使用Cerner系统。

Like, you're new at this. You are good at ambulatory, at outpatient. You're doing a really good job for us in Portland. We wanna split the baby here and do one system with Epic for our outpatient clinics and one system with Cerner for our inpatient clinics. Oh, yeah.

这种做法总是有效的。但朱迪拒绝了。她说这是个糟糕的选择，错误的决定。不在乎你们选择谁，但为了患者和整个系统的利益，确保账单处理和系统正常运作，实现门诊与医院间病历传输——这些你们真正需要的功能——应该只选择一家。

That always works. And Judy says no. That is a bad choice. That is the wrong choice to make. And I don't care if you go with us or them, but to do the right thing for your patients and for your whole system and to make billing work and have this all function correctly and have patient records transfer between your ambulatory clinics and your hospitals, which you really, really need, you should just pick one of us.

朱迪这么说有点自私，因为Cerner确实不擅长门诊业务。

Now this was a little self serving on Judy's part because Cerner was not good at ambulatory.

这是个经过算计的高风险决策。

It's a calculated high risk decision.

但这么做确实需要极大勇气。她知道Epic在两方面都有好产品。问题在于住院系统推出时间短，市场尚未建立信任。是的，但Epic当时仍是个小角色。

However, definitely super ballsy to do this. But she knew that Epic had a good product in both. The problem was just that their inpatient product was still new, and so didn't have trust yet in the marketplace. Yep. But she's still a pipsqueak.

当时Cerner年收入10亿美元，而Epic大约才略超5000万美元。谈判深入后，有次技术尽职调查会议，凯撒要求两家公司演示系统如何应对其高并发数据量——记住，850万患者和11000名医师的庞大体系。

I mean, Cerner's a billion in revenue. Epic is, like, somewhere slightly north of 50,000,000 at this point in time. So they go a little further in the process. And at one point, there's a technical due diligence meeting where Kaiser asks both companies to come in and present to them about how their systems are gonna handle all the volume of concurrent data transactions that Kaiser has. Remember, eight and a half million patients, 11,000 physicians is a high volume system here.

是的。听众们，这是个精彩的故事。这几乎是交易的最后关头了。就是说，我们已经接近做出决定，但还没最终敲定。

Yes. And listeners, this is a great story. This is kinda the eleventh hour of the deal. This is, hey. We're pretty close to a decision, but we haven't made it yet.

你们能不能都来同一栋大楼，坐在不同的会议室？然后一整天里，我们会来回穿梭，轮流花一小时与你们各方交流，根据听到的另一个提案构思问题，再回来向你们提问。所以如果你是其中一方团队，就能通过这些问题间接了解另一个房间里的提案内容，以及为什么我突然要被追问这个新话题。

Can you both come to the same building and sit in different conference rooms? And throughout the day, we're gonna bounce back and forth and keep spending an hour with each of you, formulate some questions from hearing the other pitch, and then come back and ask you those questions. And so if you're on one team or the other, you can kinda learn through the questions what is being pitched in the other room, and why am I suddenly being grilled on this new topic.

当时Epic团队正在做筹备，为这场重大会议做准备。团队原本决定通过理论演示来应对这个问题——讲解Epic的单系统架构原理，理论上系统能同时承受多大负载。但故事是这样的：总裁卡尔·德沃夏克在前一晚飞抵加州，与团队会面后看到这个计划就说：伙计们，不行。我们需要用Excel精确模拟凯撒医疗全天在系统中的交易流程，展示我们的系统将如何处理，证明我们有远超所需的带宽能力来支撑他们的系统，绝不会宕机。

So the Epic team is doing their planning, and they're getting ready for all the preparation for this really big meeting. And the team had decided that the way they were gonna handle this question was to do a theoretical presentation about how Epic's architecture worked, the single system, and theoretically, how much load could the system handle all at once. And the story is that Carl Dvorak, the president, flew in to California the night before the pitch, meets with the team, sees this plan, and is like, guys, no. We need to model out in Excel exactly what Kaiser's transaction flow is gonna be throughout the day in the system and how our system will process it and prove to them that we have far in excess bandwidth capability to handle their system, and it'll never go down.

因为他们之前只是在理论公式层面做过推演，但卡尔知道Epic的优势在于——如果能彻底展开推演并真正建好电子表格，就能实际证明我们的性能会更优越。

Because I think they had done it at sort of a theoretical formula level, but Carl knew that Epic had the advantage here, that they actually could, if they played it all the way out and really built out the spreadsheet, show, actually, we're gonna be more performant for you.

没错。于是他和团队在演示前夜通宵达旦。我不确定朱迪是否也在场，估计她也在。第二天会议上，他们向来回比较两家方案的凯撒医疗展示了这个模型。

Yep. So he and the team pull an all nighter the night before the presentation. I don't know if Judy was there as well. I assume she was too. Come in, and they show the model during these meetings that Kaiser is having back and forth between the two teams.

随着时间推移，情况逐渐明朗：Cerner没有进行同等程度的建模，无法向凯撒证明其系统能处理交易流量。我想这就是转折点，Epic团队意识到：啊哈，我们要赢了。

And as the day is going on, it becomes really clear that Cerner has not done a similar level of modeling and can't actually prove to Kaiser that their system is gonna be able to handle the transaction flow. And I think this was the moment when the tide turned that Epic was like, oh, yeah. We're gonna win this thing.

但当时结果并未立即明朗。他们确实赢得了重要分数，但据我所知，凯撒后来还是去找Cerner说：我们很感兴趣，能否在这基础上做股权交易？我们能否通过入股来换取这笔大单？

But it still wasn't obvious right away. I think they earned big points there. But my understanding is that Kaiser still went to Cerner and said, we're interested. Can we do an equity deal on top of this? Can we take part of the company in exchange for basically giving you this big deal?

我记得Cerner同意了。

I think Cerner said yes.

是的。至少我们听到的版本是：在最后决策前的关键时刻，凯撒对两家公司表示：我们希望获得贵公司的认股权证。作为美国最大医疗系统，这将是你们能获得的最大合同。

Yeah. The story, as we heard it at least, is that at the last minute, then right before the decision, yeah, Kaiser came to both companies and said, hey. We'd really like warrants in your company. We're the biggest health system in America. This is the biggest contract you're gonna get.

为达成合作，我们要持有你们的部分股权。据说Cerner确实为此交易提供了10%的公司股份，可见其重要性。

We want some equity in your companies for working with us. And apparently, Cerner did offer them 10 of the company for this deal. That's how important this was.

于是他们来到Epic，然后说

So then they come to Epic, and they say

接着他们来到Epic，他们就像在问，好吧，你对这事有什么要说的？而朱迪直接说，不。我们不会这么做。不会为你这么做。也不会为任何人这么做。

Then they come to Epic, and they're like, well, what do you have to say about that? And Judy's like, no. We're not gonna do it. We're not gonna do it for you. We're not gonna do it for anybody.

而且这是错误的选择。如果我们为你破例，就得为所有大客户都这么做，最终对你们也不利。所以绝对不行。但他们最后还是选择了Epic。

And it's the wrong thing to do. If we did it for you, we'd have to do it for all our big customers, and then that would turn out poorly for you too. So absolutely not. And they still picked Epic in the end.

尽管如此，经过架构比拼，以及那句'不，你们必须在我们中选一个'，Epic依然胜出。是的。在整个谈判过程中始终坚持立场。

Through that, through the architecture bake off, and through the, no, you have to pick one of us, Epic still won out Yeah. And stuck to their guns all the way through that negotiation.

我认为这恰恰说明了住院、门诊和计费系统间的稳定性和连续性有多重要。因为只有Epic能提供这种保障。

Which I think really should just tell you how important the stability and continuity of the system across inpatient, outpatient, and billing is. Because Epic is the only one that can offer that.

对了，之前我说24家不同公司合并成Cerner时，忘了提到我正在看的这张图表是在Cerner收购西门子之前的数据。所以还有另外12家合并成西门子的公司后来也并入了Cerner。

Yeah. By the way, earlier when I said 24 different companies merged together to create Cerner, I forgot that this chart that I'm looking at predates when Cerner then bought Siemens. So then there's another 12 companies that had merged together to become Siemens that merged also into Cerner.

没错。我们稍后会再谈西门子收购案，我记得是2014年发生的。但关键是，这就是Epic制胜的原因。

Yep. We're gonna come back to the Siemens acquisition in a minute. I think that was 2014 when that happened. But, yeah, this is key. This is why Epic wins.

是的。他们赢得这笔交易后，收入基本一夜之间翻了两三倍。《洛杉矶时报》在交易宣布时写道：'就其规模而言，Kaiser的Epic系统可能成为行业的T型车——并非首创，却是首个惠及大众的典范。'此后，Epic被奉为新的黄金标准。如果你是医院系统，如果你是考虑重新招标电子病历的CIO或CEO——看啊，全球最大的Kaiser系统刚刚选择了Epic，而且是在有诸多不利因素的情况下做出的选择。

Yep. So they win the deal, basically doubles or triples revenue overnight. The LA Times writes about the deal when it gets announced, quote, because of its scope, the Kaiser Epic system could become the model t of its industry, Not the first of its kind, but the first to reach masses of people. Once this happens, Epic gets elevated to the new gold standard. If you're a hospital system, if you're a CIO or a CEO looking to rebid your EMR well, Kaiser, the biggest system in the world, just chose Epic, and they chose it over all of these reasons not to.

这里面肯定有非凡之处。自然，你现在会考虑Epic，而Epic也必然会在评估中表现优异。

There must be something really good in there. Like, of course, you're now gonna consider Epic, and, of course, Epic is gonna perform really well in these evaluations.

是的。起初只是稍有助益，但在系统上线几年后，整个实施完成且运行良好没有崩溃时，才真正打开了局面，大约是在2002/1978年那段时间。

Yeah. It helps a little bit at first, but after the go live a few years in, after the whole implementation took place and they didn't tip over and it did go well, that was really when the floodgates opened, sort of in that 02/1978 time frame.

没错。到了2007年2月，Epic的收入已达到5亿美元。这意味着他们在与Kaiser合作后又增长了3倍，几乎是合作前的8倍，接近10倍。他们正真正转型为一家大公司。

Yep. So by 02/2007, Epic has hit 500,000,000 in revenue. So another three x what they were doing once they added Kaiser, and, like, eight x what they were before Kaiser, almost 10 x what they were before Kaiser. They're really starting to transform into a big company.

我曾与一位前员工交谈，询问公司的转折点是什么。这位员工说，赢得Kaiser合约后，我们从每月招聘10名应届毕业生，突然变成每月有数百人涌入公司大门以满足扩张需求。

I spoke with one former employee, and I was asking what were the inflection points in the company. And this employee said, oh, after we won the Kaiser deal, we had been hiring, like, 10 kids a month out of college, and it now felt like hundreds a month were just flowing into the doors so we could scale.

这让我们马上要谈到Epic位于威斯康星州维罗纳市的标志性园区了。

Which will bring us in a minute to epic's epic, shall we say, Verona, Wisconsin campus.

是的。在我们叙事中略过的一点是：2000年代初还发生过另一件事，读起来像是Epic可能经历的平行历史。想象你是一家小公司，大公司找上门说：'我们能合作开发新产品吗？你可以分销给你的客户，我们也会以我们的品牌分销——但你能分得部分收入。'

Yeah. And one thing just for our storytelling narrative there we kinda skipped over was there's another thing that happened in the early two thousands that reads a little bit as a sort of alternate history for what could have happened at Epic. Imagine you're a small company, and a big company comes to you and says, can we co develop a new product together? You can distribute it to your customers. We'll distribute it to our customers, you know, under our brand name and everything, but you get some of that revenue.

我们会与你共同开发，这确实能提振业务。若你缺乏经验，这听起来很诱人——'或许该试试'。历史上不乏成功案例，所以格外有吸引力。

And we'll sort of build this with you, and it really will charge your business up. And if you don't know any better and you've never done it, it kinda sounds appealing. Maybe we should do that. And there are many instances of it working. So, you know, that's extra tempting.

我最喜欢的失败案例是HP iPod。还记得吗？

My favorite weird example of this in history of it not really working is the HP iPod. Do you remember this?

噢对，我记得。我可能还拥有过一台——不。

Oh, yeah. That's right. I do remember this. I think I might have had one. No.

我有台YouTube特别版iPod，红黑配色的。

I have one of the YouTube iPods, the red and black one.

听众们可以搜索下，那是个奇特产物——iPod背面印着HP标志。这充分说明当时苹果处境多弱势：竟允许HP在完全由苹果设计的产品上贴牌，只为获得HP的销售渠道和分成。当然，这也能通过iTunes等带动其生态系统。

Listeners, Google it. It's this really odd thing. It's an HP brand on the back of an iPod. That tells you all you need to know about what a weak position Apple was in at the time that they were willing to let HP put their brand on something entirely created by Apple to get HP's distribution and get some cut of that revenue. And, of course, it would have bootstrapped their ecosystem since it used iTunes and all that.

但Epic遇到的情况类似：荷兰飞利浦公司找上门说'我们想合作开发放射科专用产品，你们负责主要开发，我们提供客户关系和分销渠道'。

But that's basically what happened here. So Philips, the Dutch company, comes to Epic and says, we wanna do something focused on the radiology segment. You do a lot of the development work. We have the customer relationships and distribution. Right.

因为他们很可能在卖这些机器。

Because they're probably selling the machines.

是的。我们飞利浦将获得Epic整个IT系统的授权。你们已经在销售的所有产品，我们也想卖。

Yes. We, Philips, will get a license to Epic's whole IT system. Everything that you already sell, we wanna sell also.

哦，哇。

Oh, wow.

而且我们会以飞利浦外部企业解决方案的名义向客户推广。他们将购买飞利浦品牌版的Epic系统。

And we're gonna market that as Philips' externity enterprise to our customers. They're gonna buy a Philips branded version of Epic.

有意思。我猜飞利浦在欧洲等美国以外地区也有很多客户吧？所以这是走向国际化的途径。

Interesting. And I imagine Philips probably has a lot of customers not in America too, like in Europe. So this is a way to go international.

没错。于是Epic开始在荷兰招人，组建团队，花了至少一年时间筹备。我记得他们甚至正式推出了。

Right. So Epic starts hiring people in The Netherlands. They build up this team. They spend multiple years or at least a year building it out. I think they even launch it.

但整个项目最终失败了。推出后一两年内，这次尝试成了代价高昂的弯路，公司因此对合作产生了强烈的抵触心理。在那个时期，Epic团队眼中的合作意味着：一、组织外不可控因素；二、高风险；三、历史上从未成功过。这是不可控的依赖关系，他们将这些教训内化为——专注于可控事项，直接面向客户，不再尝试任何花哨的合作整合。虽然这是过度简化，但可以说Epic后来封闭、不互操作等特质的部分基因，正是源于这次失败的合作。

The whole thing ends up folding. And within a year or two of coming out, it was a really expensive detour, and the company develops this intense scar tissue for partnerships. Partnerships at this era to the Epic team means, a, stuff I can't control outside my organization, b, big risk, c, never in our history do we have an example of it working. This is an uncontrollable dependency, and they sort of internalize this scar tissue as stay focused on what we can control, go directly to the customer, don't try to do any fancy partnership integration stuff with other people. And that's oversimplifying it, but I think it's still reasonable to say that some of the DNA of what Epic would become, and they would take tons of arrows for this, this closed, not interoperable, blah blah blah.

某种程度上确实源于这次失败的合作。

Some of it stems from this failed partnership.

和飞利浦的合作。没错。完全同意。不过他们现在终于又重新合作了，虽然是在十五到二十年之后。

With Phillips. Yep. Totally. They're now partnering again, finally. But, yeah, like, fifteen, twenty years later.

是的。感谢Health API提供这个线索。总之在2000年代末期，Epic一心专注自主开发。

Yes. And thanks to Health API guy for the tip on that. Yeah. So at this point in the late two thousands, Epic is eyes on the prize. We're building everything ourselves.

我们可以靠自己赢得大客户。我们可以站稳脚跟不妥协，不必放弃公司的任何部分。价格就是价格，我们知道我们能兑现承诺。现在是时候投资我们的未来了。他们是如何投资未来的？

We can get big customers on our own. We can stand firm and not negotiate, not have to give up pieces of our company. The price is the price, and we know that we're gonna deliver. And so it's time to invest in our future. How do they invest in the future?

维罗纳园区。对于听众中可能少数了解Epic公司或过去与他们打过交道的人来说，如果你有所了解，几乎肯定知道他们的企业园区。

The Verona campus. So for the probably minority of you listening who know anything about Epic as a company or you've been involved with them in the past, if you have, you almost certainly know about their corporate campus.

是的。

Yes.

关于这个园区的诞生有两种说法。首先是朱迪的儿子，那时他其实在微软雷德蒙德分部当开发员。朱迪和卡尔一直深受微软做事方式的启发。有次朱迪探望儿子时说：'嘿，能带我去参观雷德蒙德的园区吗？我们在考虑扩建，地方不够用了，我想看看那边是什么样子。'

So there's sort of two stories of how the campus came to be. First is Judy's son, by this point in time, is actually working at Microsoft in Redmond as a developer. And Judy and Carl had always been inspired by Microsoft's way of doing things. And so one time when Judy's visiting her son, she's like, hey. Can you go give me a tour of the campus in Redmond?

她对雷德蒙德的印象非常深刻，我想任何去过的人都会这样觉得。

We're thinking about expanding. We're outgrowing our space. I wanna see what it's like there. And she's really impressed by Redmond as I think anybody who goes there would be.

没错。尤其是那个时代。那会儿还没有谷歌总部，可以说是童话般的科技园区。

Yep. Especially in this era. It was sort of pre Googleplex. It was kind of the fairy tale tech campus.

对，那是谷歌之前的谷歌。她觉得'这就像大学校园'

Yes. It was Google before Google. Yep. And she's like, this is like a college campus

这里的氛围很棒。运动场、大量建筑，而且都很低矮，两三层高，大量户外空间和步行区。每个人都有独立办公室。太完美了。于是朱迪回来后

here, the atmosphere that you've got. Sports field and tons of buildings, and all of them are pretty short, two, three, four stories, a lot of outdoor space, walking space. Everyone gets an office. This is perfect. So Judy comes back

几乎原封不动照搬了微软的园区策略。

and basically copies the campus strategy of Microsoft almost exactly.

他们原本待在那栋改造过的校舍里。想想他们的起点和现在有机会建造的东西...他们把校舍改造得很不错。

They had been in that renovated schoolhouse. I mean, if you think about where they came from and sort of what they now have the opportunity to build, They had renovated the schoolhouse to be nice.

但确实。那远在他们成为年收入五亿美元的公司之前。

But Yeah. That was well before they were a half a billion dollar a year revenue company.

是的，完全正确。

Yes. Exactly.

于是她出去在威斯康星州维罗纳买下了一千英亩农田，那里就像雷德蒙德一样，是一个看起来田园诗般的郊区，距离麦迪逊市区约半小时车程。或者说，可能在微软入驻前雷德蒙德也是田园风光。但正如微软某种程度上拥有雷德蒙德，Epic在精神上拥有维罗纳。他们在那里建造了这个令人难以置信的园区。

So she goes out and buys a thousand acres of farmland in Verona, Wisconsin, which just like Redmond, is a kinda bucolic looking suburb about half an hour outside the city in Madison. Or I guess maybe Redmond was bucolic before Microsoft everybody got it built up. But just like Microsoft kinda owns Redmond, Epic owns Verona spiritually. So they build this incredible campus there.

与微软截然不同的是，它不像微软建筑那样实用主义。Epic当时已经在做这种童话般的奇思妙想，你从他们的产品名称中就能看出些端倪。但是大卫，我们听说过的那个校舍壁炉的故事是什么来着？

And what is very different about it than Microsoft is it is not utilitarian the way that the Microsoft buildings were. A thing that was already happening at Epic was this fairy tale whimsical thing that you can kinda see in their product names. But, David, what was the story we heard about the schoolhouse fireplace?

对，好的。这是关于Epic园区的第二个故事。就像你之前说的，本，在维罗纳之前，总部设在麦迪逊一栋他们买下并翻新的旧校舍里。在翻修过程中，设计师决定在其中一间主要会议室里安装一个壁炉，让它感觉更温馨。

Yeah. Okay. So this is the second story of the Epic campus. So like you said, Ben, before Verona, the headquarters was in an old school building in Madison that they bought and renovated. And as they were renovating it, the designers decided that in one of the main conference rooms, they they were gonna put a fireplace in there to make it feel more homey.

没错，就像威斯康星的小木屋。

Yes. Like a Wisconsin lodge.

是的。我甚至不确定是不是设计师的主意，但我觉得朱迪和公司其他人认为这很有威斯康星湖畔木屋的感觉。那就索性贯彻这个风格。于是他们把它装饰得像木屋，墙上挂了雪鞋、毛皮和斧头之类的东西。

Yes. And I don't even know if the designers did that, but I think Judy and the company were like, well, this kind of feels like a Wisconsin Lakes Lodge. Let's lean into it. And so they decorated it like a lodge. They brought snowshoes and furs and, like, a axe that they put on the wall and stuff.

结果这成了整栋楼最受欢迎的房间。每当客户来麦迪逊，他们都想在这个'没错'木屋会议室会面。所以现在他们要建新园区时，朱迪就说，不如把这个木屋概念——

And it ends up becoming the most popular room in the building. And anytime customers are coming to Madison, they always wanna meet in the lodge Yes. Conference room. And so now they're building this new campus, and Judy's like, oh, well, let's take the lodge idea and

彻底发扬光大。

Really blow it out.

发挥到极致。

Maximize it.

没错。他们在建设新园区时，将这种童话感放大了十倍。他们雇用了2008年2月负责迪士尼加州冒险乐园翻新的同一家公司。

Yeah. So they inject this fairy taleness times 10 when they're building out the new campus. They hire the same firm that did the Disneyland California adventure renovation in 02/2008.

我觉得这甚至更直白了。他们聘请了两家建筑事务所，一家就是你说的那个。嗯哼。另一家则是为微软雷德蒙德园区建造了很多建筑的公司。

I think it's even more on the nose on that. They hired two architecture firms. One is that. Uh-huh. And then they also hired the firm that built a lot of the Redmond campus for Microsoft.

哦，真的吗？是的。哇。这太疯狂了。我是说，完全是《爱丽丝梦游仙境》的风格。

Oh, is it really? Yep. Wow. And it's crazy. I mean, it's Alice in Wonderland stuff.

这里有《哈利波特》的灵感元素，也有《绿野仙踪》的启发。只要谷歌一下Epic威斯康星州维罗纳园区的照片，我们也会在节目笔记中放一些链接。简直疯狂。但对那些刚毕业、想感觉自己还在大学里、想去一家看起来有趣的公司工作的新员工来说，这极具吸引力。

It's Harry Potter inspired stuff. It's Wizard of Oz inspired stuff. Just Google pictures of the Verona campus for Epic, and we'll link to some in the show notes too. It's bananas. But it is extremely attractive to new hires coming out of college who want to kinda feel like they're still in college and wanna go work for a company that seems fun and interesting.

Epic的文化有两面性，但不知怎的却相得益彰。一边是这种傻气、异想天开的童话感，另一边则是这种拼命驱动、不惜一切代价取胜、以绩效为导向的 fierce competitor。它就是两者的结合。要理解这家公司，你必须同时记住它的DNA里并存着这两种特质，我认为这是因为Judy本人就是如此。

And Epic is this sort of two sided culture that seem to play well together somehow. This goofy, whimsical, fairy tale thing and this hard driving, win at all costs, performance oriented, fierce competitor. And it just is both. To understand the company, you have to hold in your head that the DNA of is both of those things concurrently, and I think it's because that's what Judy is.

没错，百分之百正确。完全说到点子上了。我脚本里本来有个问题：为什么要这样设计园区？这就是原因——我们要招聘超级聪明、年轻、渴望成功的应届毕业生。

Yes. A 100%. That is completely spot on. I had in my script here the question of all this is why on the campus, and that is exactly why. We are hiring super smart, young, hungry, new college grads.

怎么吸引他们来威斯康星州的维罗纳？很简单，我们要为他们打造一个乐园。

How are we going to attract them to Verona, Wisconsin? Well, we are gonna create a paradise for them.

是的。有些有趣的数据：占地1700英亩，其中410英亩是园区，其余是农场。

Yes. So some interesting stats. It's 1,700 acres. 410 of them are the campus. The rest is the farm.

现在共有89栋建筑，4个室内礼堂总计18000个座位。最大的'深空'礼堂是世界上最大的地下礼堂，有11400个座位。这可是一个礼堂啊。

It now covers 89 buildings. There are four indoor auditoriums with 18,000 seats total. The big one, Deep Space, is the world's largest subsurface auditorium. There are 11,400 seats. This is an auditorium.

这相当于把两个无线电城音乐厅的观众塞进一个巨型地下企业礼堂里。座位数更接近大通中心球馆，比起其他我能想到的礼堂，它更像个篮球馆。深入地下74英尺。当初建造时的逻辑是：'我们永远不可能发展到11400人'。

This is two Radio City Music Halls full of people smashed together in one giant auditorium underground on a corporate campus. The number of seats is much closer to a Chase Center. It's much closer to a basketball arena than it is to any other auditorium that I can think of. It goes down 74 feet beneath the surface. I mean, the whole logic behind it is when they built it, they thought, oh, we'll never grow to 11,400 people.

我们可以在这里举行全体员工大会，这显而易见。但这里也可以成为我们所有客户和整个生态系统聚集的地方。当然，现在他们实际上已经装不下了，因为规模超出了容纳能力。甚至连他们自己的员工都无法全部参加那里的全体会议。

We can have our all hands in here. No brainer. But this can also be the place where we have all of our customers and our whole ecosystem can come here. Of course, now they don't actually fit in there because they've outgrown it. Not even all their employees can come to all hands there.

建造它的逻辑是他们曾有一个电影院用来举行月度全员大会，他们希望在新园区也能有这样的机会。这太疯狂了。我的意思是，当你看着它时，简直不敢相信这座建筑的规模。

The logic for building it was that they had a movie theater that they used to do their monthly all hands meeting, and they wanted to sort of have this opportunity to do it on their new campus too. It's wild. I mean, when you look at it, you just can't believe the scale of this building.

没错。好吧。我觉得现在正是时候，既然我们谈到了园区和Epic文化，那就该好好聊聊Epic文化了。

Yep. Alright. I think now is the right time while we're talking about the campus and epic culture to really talk about epic culture.

是的。因为你首先要明白的是，朱迪称它为软件工厂。工厂。当你不断观察时，你会想，为什么这么奇怪？最大的启示在于朱迪的思维——因为他们从不收购其他公司，公司除了制造软件外没有其他核心能力，所以他们本质上就是一个批量生产软件的工厂。

Yeah. Because the first thing that you have to understand is Judy refers to it as a software factory. Factory. When you keep looking at it and you're like, why is it so weird? The biggest takeaway is in Judy's mind, since they don't ever go buy any other companies and they don't have any competencies at the company other than making software, What they are is a factory that churns out software.

他们吸纳软件开发人员，将其转化为医疗行业的软件产品。

They take in software developers, and they turn that into software for the medical industry.

这很有趣。显然，她在这方面走在了时代前列

That's funny. Apparently, she was just ahead of her time with

人工智能工厂。

The AI factories.

现在NVIDIA和戴尔不也把数据中心称为AI工厂嘛。是的。

Was it NVIDIA and Dell are calling, know, yeah, AI factories now. Yeah.

没错。所以当你思考时就会豁然开朗：一个将开发者转化为医疗代码、医疗应用的工厂应该是什么样子？答案就是威斯康星州的维罗纳。

Yeah. Absolutely. And so it starts to click and make more sense when you think, well, what would a factory for turning developers into medical code, medical applications look like? Well, Verona, Wisconsin.

对。既然我们谈到文化，这个园区最惊人的特点之一是Epic有十条戒律。Epic十诫就像圣经里的摩西十诫一样。他们在整个园区的每个卫生间和休息室都张贴着这些戒律。任何到访的游客——园区是对公众开放的——都能在卫生间里看到这十诫。

Yep. So while we're on culture here, one of the most amazing things about the campus is Epic has a list of 10 commandments. So the Epic 10 commandments is like, you know, Moses in the Bible here. They have them posted in every bathroom and in every break room across the entire campus. And so any visitor who goes there, and it's open to the public, you can just go in and see the 10 commandments in the bathrooms there.

十条戒律如下：第一条，不要上市。第二条，不要收购或被收购。

The 10 commandments are, number one, do not go public. Number two, do not acquire or be acquired.

顺便说，前两条无需向员工传达。只有CEO才能决定这些事。所以把它们列为戒律很有趣，这表明朱迪多么深刻地认为需要让所有员工都牢记。

By the way, those first two things, you don't need to communicate that to employees. Only the CEO can do either of those things. So it's just funny to put it as commandments. That shows how deeply Judy feels it needs to run-in all of the employees.

我认为这么做的另一个重要动机，并将其张贴在洗手间，是为了让每位来访客户都看到——这些也是对客户的承诺。

And I think the other big motivation for doing this is and having it there in the bathrooms is every customer who comes to visit. It's right there to the customers too.

没错。

Right.

我们永远不会上市。永远不会被收购，也永远不会收购其他公司。你可以相信这将永远是一个独立系统。是的。是的。

We will never go public. We will never be acquired, and we will never acquire another company. You can trust this is one system forever. Yep. Yep.

好，这是一二条。第三条：软件必须可靠。第四条：现实必须符合预期。第五条：信守承诺，包括未明言的承诺。

Okay. So that's one and two. Number three, software must work. Number four, reality equals expectations. Number five, keep commitments, even the unspoken ones.

第六条：专注能力。不容忍平庸。第七条：设立标准。公平待人。第八条：保持勇气。

Number six, focus on competency. Do not tolerate mediocrity. Number seven, have standards. Be fair to all. Number eight, have courage.

你容忍什么就代表你主张什么。第九条：传授哲学与文化。第十条：保持节俭。不为运营举债。

What you put up with is what you stand for. Number nine, teach philosophy and culture. And number 10, be frugal. Do not take on debt for operations.

没有一条涉及医疗保健。是的，我看的时候一直在想，希望能找到'每个生命都重要'或'以患者为中心'之类的内容——但没有。这就是如何经营公司。这就是我对经营公司的全部观点，句号。

Zero of those pertain to health care. Yes. When I was looking at them, I kept thinking, oh, I'm gonna find something here about every life is important or the patient is at the center of everything or no. This is how to run a company. This is my opinion on how to run a company, period.

是的。具体回应你的观点，我认为这是运营软件工厂的绝佳方式。

Yep. And I think specifically to your point, this is a pretty good way to run a software factory.

是的。这些东西挂在浴室里。关于校园的其他趣事是，每当签下新客户时，他们会播放婚礼钟声，整个校园都能听到，以此表明这是一种终身承诺。就像我们已经与这位客户‘结婚’，共度余生。

Yes. So these hang in the bathroom. Other interesting things about the campus, they have wedding bells that will play campus wide when a new client is signed, just showing that that's the type of commitment that this is. It's a we've now married this client for the rest of our lives.

对啊。就像婚礼进行曲，你知道的。就像是他们版本的‘敲锣’。

Yeah. It's like the wedding march, you know. Like, that's their version of, like, ringing the gong.

没错。我觉得我们还没怎么聊过在那里工作是什么体验。现在可能是个好时机。如果你是个聪明、有抱负的大学毕业生，这里简直是个绝佳的训练场。人们指责他们像邪教，但在某些方面这是件好事。

Yes. And I think we haven't really talked that much about what it is like to be an employee there. So this is a probably good time to do that. This is an insanely awesome training ground if you are a smart, ambitious person out of college. People accuse them of being cult like, but there are ways in which that's a good thing.

我的意思是，他们接纳刚开启职业生涯的你，然后教你一切。我说的‘一切’，包括如何记笔记——在黄色法律便签纸上有一套传奇的笔记方法，还有写邮件的黄金准则。这些都是经过多年淬炼的硬核实践，他们相信通过迭代、测试和数据验证。

I mean, take you fresh out of your career, and they teach you everything. And when I say everything, I mean how to take notes. There is an epic way to take notes on a yellow legal pad. There is an epic way to write emails. And these are, like, hardened practices over the years that they just believe through iteration, through testing, through data

可能一直要追溯到尼尔和Meditech的时代，还有——

Probably going all the way back to Neil and Meditech and

是啊。

Yeah.

在波士顿的那三天。

The three days in Boston.

这就是做这件事的最佳方式，句号。所以我们要教会所有人做每件事的最佳方式，每个人都会变得相当标准化。我们可以相信，一旦你通过Epic系统的锻造，从另一端出来时，你就能以极其高效的方式运作，完美契合我们的机器——在这里人们能真正彼此信任。正因为这种高度信任，中层管理者很少。你理解每个人都在其中运作的体系，不需要去管理混乱。

This is the best way to do this, period. And so we're just gonna teach everybody the best way to do everything, and everybody is gonna be, like, reasonably robotic. We can sort of trust that once we squeeze you through the Epic system, when you come out the other side, you are able to operate in a way that works really, really, really well in our machine where people can really trust each other. So because of that high level of trust, there's very few middle managers. You understand the system that everybody else works within, and you don't have to corral chaos.

大多数招聘对象都是应届毕业生，所以他们长期待在那里。他们没有预算——只有在像这样高信任度的环境中才能做到这点。当然有些财务控制，但朱迪有个经典故事：她拜访客户时，对方常说‘这方案是对的，但今年没预算，我们明年再做’。她觉得这太蠢了。

Most of the people that are hiring are right out of school, so they've been there for a long time. They don't have budgets, which you can kind of only do when you have a high trust environment like this. I mean, there's some financial controls, of course, but Judy's got this great story that she used to go see customers, and they'd say, oh, this is the right thing to do. I just don't have the budget for it this year, so we're gonna push it next year. She's like, that's stupid.

或者客户会问她‘今年能挤进预算吗？因为不花掉这笔钱就会过期’。她会回答‘这也够蠢的’。所以在我的公司，我们不会有这种预算制度。他们几乎不看重头衔。

Or they would tell her, can we squeeze this in this year? Because if I don't spend this money, I'm gonna lose it in my budget. And she would say, well, that's also stupid. So at my company, we're not gonna have budgets like that. They're super light on titles.

无论你在公司二十年还是六个月，当你去参与项目时，可能都会递给客户一张写着‘实施’的名片。每个人都要做沉浸式体验——我是说所有软件开发人员都必须花时间在临床环境中，比如手术室，直接观察工作流程。是的。我想刚开始时，你需要

You might have a business card, whether you've been there twenty years or six months that says implementation that you hand to a customer when you go and do an engagement. Everyone does immersion trips where the software developers I mean, everyone is required to spend time in clinical settings like operating rooms to directly observe workflows. Yep. I think when you start, you have

完成五次，之后每年还要做更多。哇。

to do five of them, and then you do more every year. Wow.

Y Combinator倡导的理念是：去和客户交谈，花时间了解客户。Epic公司一直这么做。这就是Epic的方式，我认为当创业公司将之奉为信条时，全世界才逐渐意识到其价值。但公司每个人都在医疗环境中花时间与客户交流，这极具价值。在开发方面，他们采用极其规范的软件方法论来最小化缺陷。

Y Combinator preaches, go talk to your customers, spend time with customers. Epic's been doing this forever. This is the Epic way that I think the rest of the world sort of woke up to when startups internalized as doctrine. But every person in the company spending time in medical settings talking to customers, hugely valuable. On the developer side, there's a super prescriptive software methodology that they use to minimize bugs.

所以入职时要接受六个月的强化培训。开始编程时，整个系统设计都围绕最小化代码编写与测试之间的时间间隔。如果发现缺陷，作为原始开发者必须立即停下手头工作修复它，这样你还能保持完整的上下文记忆

So you go through this intensive training for six months when you join. And then when you start programming, the whole system is designed around minimizing the number of hours between when a line of code is written and then when it is tested. So if a bug is found, then you drop everything as the original developer, and you fix it so that you still have the whole context fresh in your

清晰。

head.

你不会拖上几个月才测试系统。通过这种方式，缺陷不会累积成更大问题，而是被立即捕获。

You don't sort of go months, then the system gets tested. And bugs aren't allowed to compound into bigger problems this way. They get caught right away.

我记得规定是：每个开发者必须修复自己的缺陷。

And I believe the rule, right, is that every developer must fix their own bugs.

我也是这么理解的。这种软件工程方法更重视零缺陷环境，因为事关人命，比其他因素都重要。所以你不一定用最快速度交付软件，甚至可能不会做出最创新、最聪明、最惊艳的前沿产品——你只需要确保交付的是无缺陷软件。

That's my understanding too. It's this method of software engineering that places way more importance on a zero bug environment because lives are on the line than other ones. So you're not necessarily gonna ship software the fastest way. You may not even ship the most innovative, clever, amazing, cutting edge. You're just gonna make sure that you're shipping bug free software.

没错。我认为原因有二：其一绝对是因为人命关天。如果处方剂量因软件缺陷出错，会导致很多人死亡。是的。

Yep. Well, I think the reasons are twofold. One, it absolutely is right that lives are on the line. If a order for the amount of dose in a prescription gets messed up because of a bug, a lot of people are gonna die. Yep.

其二，客户收入周期和账单系统的复杂性也至关重要。那里同样不能有缺陷。往好了说，医院会损失大量收入机会；往坏了说，他们可能因医疗欺诈面临联邦犯罪诉讼。

And, also, the complexity required for the revenue cycle and billing for your customers is of paramount importance. You cannot have bugs there either. Or at best, the hospital's gonna lose a lot of revenue opportunity. At worst, they're gonna get sued for federal crimes, for medical fraud.

没错。说得好。这意味着你需要一个

Yep. Great point. So that means you need a

高度稳健的系统。

Highly robust system.

是的。作为公司实施人员的工作强度堪称疯狂，就像军事级别的后勤管理。你要同时应对多个客户，这些客户都拥有地球上最复杂的系统。彼得·德鲁克曾有名言，称医院是我们迄今为止尝试管理的最复杂的人类组织形式。

Yes. Work done as an implementation person at the company is insane. It's like military level logistics. You're handling multiple customers, all of which are among the most complex systems on Earth. Peter Drucker famously referred to hospitals as the most complex form of human organization that we have ever attempted to manage.

你必须每天了解客户的所有依赖关系以及十几项相互关联事务的状态。作为年轻人，你实际上处于这种高压、高风险的领导角色中。虽然每天可能要工作十到十二小时，但许多人乐此不疲，因为你在赢。你刚毕业就在做真正的大事，和其他非常聪明的人一起。

You have to understand all these dependencies at the customer and the status of a dozen interrelated things on a daily basis. You really are in this high adrenaline, high stakes leadership role as a really young person. You can work ten, twelve hours a day, but a lot of them love it because you're winning. You're doing really big things right out of school. You're doing it with other really bright people.

所以他们真的会挑选高智商、高情商的人，通常是那些非常可爱的中西部孩子来担任这些面向客户的职位。

So they really try to get high IQ, high EQ, often, like, very sweet Midwestern kids to take these customer facing roles.

是的。我认为还因为扁平化的组织结构，让你能与其他资深人士并肩工作并直接向他们学习。就像卡尔和苏米特的故事——年轻的程序员苏米特与同时是程序员的总裁卡尔共同领导项目团队

Yep. And I think also because the flat organization, like, you're also doing it alongside Yes. Other senior people and learning from them directly. Like, the story about Carl and Sumit. He did Sumit as a young programmer working on a project with Carl, the president, who's also a programmer leading

没错。

Yeah.

这种情况确实存在。

The team. Like, that happens.

如果你是个雄心勃勃、专注事业的人，没有什么比在高风险环境中与其他高绩效者团队合作并取得胜利更有趣的了。这种体验加上奇思妙想，很好地体现了史诗级的企业文化。其结果就是这成为了你生活的首要事项。如果你和许多曾在那里工作或仍在职的人交谈，会发现他们全身心投入，尽管地处偏远。这也是园区存在的另一个意义。

If you're an ambitious career focused person, there is nothing more fun than winning in a high stakes environment with other high performers as a team. That plus the whimsy encapsulates pretty well the epic culture. And the result of that is it becomes the number one thing in your life. If you talk to a lot of these people who spent time there or still work there, you're all in, and you're in the middle of nowhere. This is the other job the campus does.

你不会真正接触到其他可能让你离职去做的选择。他们让你很容易就把整个人生变成一场史诗。

You're not really getting exposed to other things you could leave and go do. They make it very easy for your whole life to become epic.

是的。你可以开车去大城市麦迪逊。没错。我知道我们一直在做这种比较，这里和校园也有直接关联。但最让我联想到的公司是微软早期的那段日子。

Yeah. You could drive to the big city of Madison. Yes. I know we keep making the comparison, and it's a direct one with the campus here too. But the company that this reminds me the most of is those early days of Microsoft.

这完全就是八十年代和九十年代在微软时的感觉，当我们和那些做研究的人交谈时。

This is exactly what being at Microsoft in the eighties and nineties was like when we talked to people doing that research.

我在为此做研究时也从一些人那里听说过。有两三次Palantir被提到，那里都是些目光炯炯、精力充沛、聪明又年轻的员工，他们被部署到这些非常紧张的环境中。但你懂行，你经历过培训，经历过流程，你配备了好的工具，你会去把事情搞定。

And I heard from some people too when I was researching for this. Two or three times Palantir came up of these sort of bright eyed, bushy tailed, smart, young people where you're deployed into these really intense environments. But you know your stuff, you've been through the training, you've been through the process, you're armed with good tools, and you're gonna go make it happen.

对。

Yep.

所以另一方面是优胜劣汰。他们积极淘汰表现垫底的百分之几员工，而且工作强度非常大。因此对于大量新员工，他们试图判断你是否能胜任，替换掉你比留着你不作为更划算。所以头几年会有很多人离职，但你知道一旦有人待了一段时间，他们就是优秀的。你可以信赖他们。

So the other side of this is eat his upper out. They aggressively trim bottom whatever percent of performers, and they work you really, really hard. And so with the vast amounts of new hires, they're trying to figure out if you're gonna cut it, and it's more cost effective to replace you than keep you as deadweight. And so you have lots of attrition in the first few years, but you know that once someone's been there for a while, they're good. You can count on them.

没错。他们的招聘方式很疯狂，现在更常见的是在招聘过程中加入编程测试。

Yep. Their method of hiring is crazy, and this is more common now to give out programming tests as a part of the hiring process.

哦，这个故事太棒了。我能讲讲吗？

Oh, this story is so good. Can I tell it?

当然，请讲。

Yes, please.

我们提到过朱迪的儿子曾是微软的程序员，这也是她去看望他的原因之一，校园灵感的部分来源。他参与公司的时间其实早于他成为微软程序员甚至成年之前。八十年代末，朱迪在招聘软件开发人员时发现，面试并不能很好地预测他们是否会成为优秀的开发人员。与此同时，她儿子大概在上七年级左右，在全州参加这些编程比赛。她和他聊过。

So we mentioned that Judy's son was programmer at Microsoft, and that's how she went to visit him, part of the inspiration for the campus. His involvement in the company actually predates him becoming a programmer at Microsoft or even an adult. In the late eighties, Judy was hiring software developers and found that interviewing them just wasn't that predictive of whether they were gonna be great software developers or not. Meanwhile, her son, I think, was in, like, seventh grade or something like that and was doing these programming competitions around the state. And she was talking to him.

我当时想，你做这些编程比赛，有这些测试，然后你还赢了一些。这相当能判断你是否是个好程序员。

I was like, well, you do these programming competitions, there are these tests, and then you're winning some of them. And that's a pretty good judge of whether you're a good programmer or not.

它们的预测性相当不错。

They're reasonably predictive.

你觉得能帮我编写这类测试吗？我想在Epic用它来面试应聘的软件开发人员，看看他们是否合格。

Do you think you could write one of these types of tests for me, and I can use it at Epic and test software developers as we're hiring them and see if they're any good?

听众朋友们，整整十八年来，这就是他们决定是否录用某人到Epic工作的方式。很多时候——我不知道这个比例是否接近100%——但有很大概率他们根本不会面试你。他们认为这些测试的预测性已经足够强。只要你测试成绩优异，就能获得工作机会。当然你会来园区参观之类的，但基本上测试高分就等于录用通知。

And for eighteen years, listeners, that was how they tested to determine if someone should work at Epic. And many, many times, I don't know if the number is close to a 100% or but some large percent of the time, they just don't interview you. They believe that their tests are predictive enough that that's it. You can get a job offer. You come visit campus and all that, but, like, you get a job offer after scoring high on this test.

而且现在不止那个测试了。还有伦勃朗测试等其他多种测试，全部系统化分类存档，每个入职者都要参加。

And it's not just that test now. There's other tests. There's a Rembrandt test. They've got a bunch of tests. It's all systemized and cataloged, and everybody takes one on the way in.

适用于公司每个岗位。

For every role in the company.

没错。听说就连餐饮团队入职时也要参加测试——虽然不是完整的开发者测试，但需要考逻辑题。

Yeah. The culinary team, we heard, takes not full software developer tests, but logic tests on the way in.

是啊，厉害吧。不过最初那个测试其实是Judy十几岁的儿子编写的，虽然现在停用了——可能是因为答案在网上泄露了——但确实沿用了很长时间。这故事挺有趣的。

Yep. Amazing. But, yeah, Judy's teenage son wrote the first test that is now no longer being used. I think the answers have gotten out on the Internet, but for a long time, was used. And it's a funny story.

但这可是八十年代的事。那时候谷歌都还没开始搞这类测试呢，在当时绝对是超前的招聘方式。

But this was in the eighties. This was way before Google was doing this kind of stuff. This was really out there hiring practices at the time.

没错。我们聊了很多内部文化，但最重要的对外影响还没深入探讨。Epic文化完全是客户至上的，就像我们之前讨论客户时说的那种程度。

Yep. So we talked a lot about the internal culture. The most important thing that we haven't really dove into yet is how it touches the outside world. The Epic culture is completely customer obsessed. And I mean that the way we talked about customer before.

Rush大学医疗系统首席信息官Jeff Gottney有句名言：'虽然Epic确实不便宜，但你永远物有所值。'在客户访谈中，这种评价反复出现——可靠、有效、从不夸大承诺。

There's a great quote from Jeff Gottney, the chief information officer for Rush University System for Health. He says, you get what you pay for a 100% of the time despite Epic being, quote, not cheap. You kinda see that echoed over and over and over again in these customer conversations as reliable. It worked. They didn't overpromise on something.

它已完全整合。到了这个阶段，没人会因为选择Epic而被解雇，就像过去选择IBM一样保险。

It is fully integrated. At this point, no one gets fired for buying Epic the same way it used to be true about IBM.

没错。客户永远是第一位的，方方面面都是。

Yep. Customers are, like, always number one. Everything.

他们通过投票决定。我的意思是，他们选择下一个开发项目的方式是：当所有客户来参加年度会议时，征集创意然后投票，把客户意见作为确定下一步计划的依据。

They vote. I mean, the way that they pick the next things to build is when all the customers come to campus for their annual conference, they ask for ideas, and then they vote and take customer input as a way for figuring out what are we gonna do next.

完全正确。公司基本上只有三种角色：软件开发人员、项目经理（即实施经理，负责新客户的实施工作），以及提供持续客户支持的技术专家。没有销售或营销部门，公司里只有大约八名所谓的'销售人员'，他们只处理主动咨询，而且全都来自项目管理或技术专家岗位。

Totally. There are basically only three roles at the company. There's software developer, project manager who are the implementations managers doing the new active implementations for new customers, and then there are technical specialists who do ongoing customer support. There's not a sales or marketing department. There are eight or so salespeople, quote, unquote, in the company who only react to inbound requests, and they all came from either project management or technical specialists.

这就是整个公司架构。技术专家是公司最大的群体，Epic的607家医院系统客户每家都拥有专属技术专家团队，对应他们使用的每个产品。比如一个医院系统，会分别有Epic Care电子病历、MyChart、Resolute、Cosmos等每个产品的专属团队。

That's the whole company. The technical specialists are the biggest group in the company. Every single customer of the 607 whatever hospital system customers that Epic has, every single customer has their own technical specialist teams for every single product that they use. So, like, if you're a hospital system, you have your own technical specialist team for your Epic Care EMR, for MyChart, for Resolute, for Cosmos, for you name it. Anything you use, you have your own dedicated team for that.

此外，每个客户还有专属的'永远最好的朋友'（BFF）。这个BFF是Epic内部单点联系人，其唯一职责就是确保客户成功使用产品。他们会每年给客户评分，与其他客户对比使用Epic工具的表现，并向CEO、CIO和CFO分别发送年度报告卡，从多个维度进行1-5分评级，同时展示与同类规模医院系统的对标数据。

And then on top of that, every customer has their own dedicated BFF, best friend forever. Like, BFF, who is a single person within Epic, and their sole job, their only job is to make sure that you as a customer are successful with their products. So this means they do things like they grade you as a customer every year, benchmarked relative to what other customers are doing and how you're doing with the Epic tools. So they will send separate report cards every year to your CEO, CIO, and CFO, and they will grade you one through five on a bunch of dimensions. And then they will show you benchmark data against other customers at your peer set of, like, relative similar sized hospital systems how you're doing.

哇，这太疯狂了。

Wow. That's crazy.

是的，我从未听说有其他公司这样做。

Yes. I've never heard of any other company that does stuff like this.

他们在客户关系中掌握着很大主动权。在2025年的今天，当客户与Epic的方案出现分歧时，虽然最终会尊重客户选择，但Epic会提出极具说服力的论证来表明他们的方案才是正确的。这形成了标准化套装产品——相比之下，Cerner的每个实施案例往往差异巨大。

Well, they have a lot of leverage in the customer relationship. I think at this point in history, you know, 2025, when the customer wants to do something a certain way and Epic wants to do something a certain way, ultimately, Epic is customer focused, so they will do whatever the customer wants. But they're going to lay out very compelling convincing arguments why their way is the correct way. And what this leads to is things like a standard package. A lot of times when people are setting up Cerner, every implementation looks completely different.

Epic有着强烈主张：请尽量使用标准配置，这样我们能轻松推送更新、添加新模块，确保互操作性完全符合设计预期。当他们建议'我认为应该这样做'时，谈判立场非常强硬——因为他们随时可以说'我觉得贵方还没准备好成为我们的客户'。

Epic is highly opinionated. Please use as much standard stuff as you can so that we can easily push out updates, or we can easily add in new modules for you, or interoperability all works exactly the way that we're thinking it should. They have a strong negotiating position with customers when they're saying, I think you should do it this way. Because at some point, they may choose to just say, you know what? I don't think you're ready to be a customer yet.

我认为今年我们会把重点放在其他地方，因为我们只会新增10到20家，也许30家新客户。

I think we're gonna focus elsewhere this year because we're gonna pick up only 10 to 20, maybe 30 new customers.

我们很乐意等待。

And we're happy to wait.

我们很乐意等到你们准备好与我们合作。实际上他们现在有足够的筹码来实现这一点。

We're happy to wait until you're ready to work with us. And they actually have the leverage to pull that off now.

关于你提到的标准实施问题，我认为与Epic获得价格折扣的唯一方式就是完全或大部分采用标准方案。我觉得可能还会根据实施的标准程度划分不同层级，偏离标准越多，需要支付的费用就越高。

To your point about the standard implementations, I believe this is the only way that you can get discounts on pricing with Epic is by doing either fully or mostly standard. I think there probably are some tiers based on how standard your implementation is, and the more you deviate from it, the more you have to pay.

我能理解这点。我知道如果你能及时跟进数据库维护、版本更新等事项，他们就会给你折扣。

I could see that. I know if you stay up to date on things like database maintenance and versioning and all that, then they give you discounts.

没错。所有这些听起来像是Epic在为自己积累力量，事实也确实如此。但这家公司及其客户关系中还存在近乎利他主义的部分。我认为这源于Judy的个人特质。

Yep. So all of this sounds sort of Epic accruing power for Epic, which it is. There is also this almost altruistic part of the company and their customer relationships. And I think this comes from just Judy and who she is as a person.

利他资本主义确实给人一种极度竞争、极度价值最大化却又利他的感觉，这大概就是我描述这家公司的方式。

Altruistic capitalism does feel like ultra competitive, ultra value maximizing altruistic capitalism is kind of like how I would describe the company.

是的。这就是对Epic的总结。尽管价格确实昂贵，但这种利他主义体现在他们基本上不会对现有客户涨价。虽然也有调整，但平均年涨幅普遍在2%左右，低于通胀水平。

Yeah. I think that's how you sum up Epic. And this altruistic piece is despite certainly being expensive, they basically never raise prices once you're a customer. They do, but their average yearly increase is about 2% across the board. So below inflation.

对比其他众多软件公司，他们可不是每年只涨2%。他们还做过诸如MyChart自创立以来从未涨价这类事情。

Compare that to lots of other software companies out there. They're not raising prices 2% every year. They also do things like they have never in its entire history changed the price of MyChart.

我们多次听说过这个说法。我觉得这是转移注意力的幌子。我们不知道底价究竟如何。我们只被告知了零碎信息。我们手上并没有完整的客户合同来汇总所有子组件的费用。

We got told this multiple times. I think that's a red herring. We don't know what the bottom line price looks like. We got told one piecemeal. It's not like we have a full contract in hand of what it looks like to be a customer and add up all the subcomponents.

说得好。我要强调两点。是的，他们以客户为中心。没错。

Good point. Two points to make. Yes. They're customer obsessed. Yes.

他们在倾听。但当然，最终是为了Epic的长期利益。作为客户选择Epic的核心原因，就是将患者互动转化为医疗系统尽可能多的收入，同时将风险降到最低。

They're listening. But, yes, of course, it's to do what's in Epic's long term interest. I mean, the core functionality of if you're a customer, the reason you pick Epic is to turn an interaction with a patient into as many dollars as possible for the health system without risking downside. With the lowest risk possible. Yes.

这就是客户选择他们的原因。而Epic的目标是什么？Epic试图赢得交易、永久立足并实现全球统治。所以他们做了许多看似以客户为中心、实则对Epic极有价值的事。比如向客户推荐第三方新软件。

So that is why the customer is picking them. And what is Epic trying to do? Epic is trying to win deals and stay in forever and achieve world domination. So they do these very interesting things that feel very customer focused and are, but are also very valuable for Epic. Like, they'll recommend alternative third party new pieces of software to their customers.

当新事物出现时——比如2020年远程医疗突然变得重要——他们会说：'这是符合HIPAA的Zoom使用方案。顺便说，我们正在开发自己的远程医疗功能。'

Some new thing comes out. Oh, it's 2020. Telehealth suddenly is really important. Here's a HIPAA compliant way to do Zoom. By the way, we're gonna start working on our own telehealth thing.

'很快就会推出。您现在可以放心使用Zoom。等我们的新模块上线，对现有客户将完全免费。'

It'll be out soon. You should feel free to use Zoom right now. By the way, when our new module comes out, it's just gonna be free to you. You're already a customer. It's just gonna be free to you.

这样客户自然不会四处寻找替代方案，毕竟知道即将免费获得。虽然初期功能简陋不会立即采用，但当它足够完善时，客户就会说：'好，我现在就用Epic版本，反正包含在企业协议里。'这种惊人的捆绑策略让我想起微软的案例。

So you're certainly not gonna go around shopping for some new thing when you know that it's just gonna come for free to you. And you're not gonna take it right away because it's gonna be too bare bones. But at some point, it'll get good enough where you can say, oh, yeah. I'll just adopt the Epic version now, part of my enterprise wide agreement. It's this kind of amazing bundling strategy that certainly reminds me of the Microsoft episode.

没错，你说得完全正确。

Yep. You're totally right.

我认为这是正确的观察角度。他们以客户为中心，因为长远来看这对Epic也最有利。这不是新发现——我突然想起杰夫·贝索斯有句话（虽然笔记里没记），大意是说长期来看客户想要的与亚马逊想要的没有区别。

I think that's the right way to look at it. They're customer obsessed because in the long term, that is the right thing to do for Epic also. And this is not a new realization. There is a Jeff Bezos quote, and I just thought of it. I don't have it in my notes.

我清楚记得他在99年左右的某个老视频里说过。是的，Epic绝对以客户为中心——再次强调，他们的客户是医院系统的CEO和CIO。

But it's something about in the long run, there is no difference between what the customer wants and what Amazon wants. And I distinctly remember him saying this in, like, '99 or something, some really old video. Yep. Epic is absolutely customer obsessed. Again, CEO, CIO of hospital systems.

因为满足这些客户，长远来看就是在满足Epic。

Because if you deliver for them, you deliver for Epic in the long run.

是啊。嗯，我是说，这有点像

Yep. Well, I mean, that's kind of like

这就像是经营公司的目标。

That's like the goal of running a company.

资本主义的理论基础。对吧？就像

Theoretical underpinning of capitalism. Right? Like

对。

Right.

总之，这是一种非常有趣的企业文化和组织形态。

So all that to say, it is a very fascinating corporate culture and organization.

没错。好了，听众朋友们，如果你们对这个行业有所了解，就知道我们还没讲到重点部分。我们已经谈到了与凯撒的交易，那确实是个大事件。

Yes. Alright. So listeners, if you know anything about this industry, you know that we haven't gotten to the important part yet. We've gotten to the Kaiser deal. That was a big deal.

讲到搬去维罗纳。理解这种文化很重要，大多数写这家公司的记者都会抓住这个可爱的噱头。哇，酷炫的园区。我得去拍些照片写篇园区特稿。但实际上在经济大衰退期间发生了更疯狂的事，一些变革性的立法通过后，给整个行业带来了大量好处也造成了许多问题。

Gotten to moving to Verona. It's important part to understand the culture, and it's like this cutesy thing that most journalists who write about the company kinda latch on to. Oh, cool campus. Like, I should go take some pictures and write a cool story about campus. There's a whole big crazy thing that happens as a part of the Great Recession and some legislation that gets passed transformative for the industry, and causes a whole bunch of good and a whole bunch of bad to happen.

但在那之前，我们要感谢节目的好朋友ServiceNow。他们正在开发令人兴奋的CRM系统。虽然我们说过ServiceNow是企业AI操作系统，但你可能不知道他们多年来还默默打造了价值超十亿美元的CRM业务。

But before we do that, this is a great time to thank good friend of the show, ServiceNow. ServiceNow has been working on something really exciting, CRM. Now I know we've talked about ServiceNow as the AI operating system for the enterprise, but what you might not know is they've also quietly been building a billion dollar plus CRM business for years.

没错。它之所以能大隐于市，部分原因是ServiceNow始终是企业数据和运营的统一平台。因此整个企业通过ServiceNow访问和交互客户数据，完全是水到渠成的事。

Yep. And part of the reason it's been hiding in plain sight is because ServiceNow has always been one single platform for all your company's data and operations. So it's a totally natural consequence that ServiceNow is also one of the best ways for the whole enterprise to access and interact with customer data.

这很有趣，因为ServiceNow从完全不同的角度切入CRM。传统CRM系统是几十年前建的，主要用来记录数据和生成报告，而不是采取行动或连接面向客户的团队。ServiceNow认为新时代的CRM不仅是销售工具，更是贯穿整个组织的服务体系。

It's fascinating because ServiceNow approaches CRM from a completely different angle. Traditional CRM systems were built decades ago primarily to record data and report on activities, not to take action or connect customer facing teams across your business. ServiceNow believes the new age of CRM is not just about selling, but also about delivering service across the whole totality of your organization.

你是说现在就提供服务吗？嘿，哟。嘿，哟。不过没错，正是这样。

You mean, like, delivering service now? Hey, yo. Hey, yo. But yes. Exactly.

想想看，如果销售、服务和运营各自使用独立系统，最终就会形成ServiceNow所称的'人工中间件'——员工需要手动在不同系统中更新相同信息。而ServiceNow是一个统一平台，提供单一事实来源。

Think about it. If you have separate systems for sales, service, and operations, you end up with what ServiceNow calls human middleware, employees manually updating different systems with the same information. But ServiceNow is all just one platform and one single source of truth.

啊，听起来是个熟悉的策略。

Ah, sounds like a familiar strategy.

哦，有点像我们这期节目一直在讨论的内容。没错。服务或销售互动会在ServiceNow平台上自动同步更新，因为它就是个统一平台。既然ServiceNow已经是企业的操作系统，难道它不该也成为你的CRM系统吗？

Oh, kinda like what we've been talking about this whole episode. Yep. Service or sales interactions automatically get updated everywhere on ServiceNow because it's just one platform. So since ServiceNow is already your enterprise operating system, shouldn't it also be your CRM?

在AI智能体崛起的当下，时机就是一切。假设客户因延迟发货联系客服，传统CRM可能只会记录投诉，但根本原因仍隐藏在运营系统中。而采用ServiceNow的现代CRM方案，AI智能体可以无缝访问跨部门数据——从库存到物流再到消费历史——不仅能追踪问题，更能真正解决问题。这不仅是客户管理。

And timing is everything with the rise of AI agents. So let's say a customer contacts support about a delayed shipment. In traditional CRM, you might log the complaint, but the root cause remains hidden in your operation system. And with ServiceNow's modern CRM approach, AI agents can seamlessly access your data across departments from inventory to logistics to consumer history and not just track the issue, but actually resolve it. It's not just about managing customers.

更是连接整个企业来提供更好的服务。

It's about connecting your entire business to serve them better.

没错。如果想了解更多关于ServiceNow现代CRM方案的信息，请访问servicenow.com/acquired，告诉他们是本和大卫推荐你的。

Yep. So if you wanna learn more about ServiceNow's modern approach to CRM, go to servicenow.com/acquired, and just tell them that Ben and David sent you.

好，我们现在来到2000年代初期。刚讲完Verona园区，你们现在对Epic的企业文化已经了如指掌了——至少是从外部能观察到的全部。现在正处于2006年2月这个非常有趣的时期。

Okay. So we're coming through the two thousands here. We just got through the Verona campus. You know everything about Epic's culture now, or at least everything that we could discern from the outside anyway. And we're in this pretty interesting era in 02/2006.

当时美国处于布什政府时期，布什在国情咨文中说：'全体美国人都必须面对日益增长的医疗成本，加强医患关系，帮助民众获得所需的医疗保险。我们将更广泛使用电子病历等医疗信息技术来控制成本，减少危险的医疗失误。'现场响起热烈掌声。

We're in the Bush administration here in America, and Bush says in a state of the union, for all Americans, we must confront the rising cost of care, strengthen the doctor patient relationship, and help people afford the insurance coverage they need. We will make wider use of electronic records and other health information technology to help control costs and reduce dangerous medical errors. Wide applause.

这是我做研究时最震惊的发现之一。外界普遍说法——包括我之前有限的认知——都认为是奥巴马医改和奥巴马政府真正推动了电子病历采纳和'有意义使用'等政策（这些我们稍后会详细讨论）。但实际上这是完全跨党派的，最早始于布什政府时期。

This is one of the craziest things to me in doing the research. The narrative out there, and certainly in as much as I knew or paid attention to any of this, was that Obamacare and the Obama administration were the ones who really pushed EMR adoption and meaningful use and all this stuff that we're really gonna get into. Totally bipartisan. Totally started in the Bush administration.

没错。为了让你们更直观地感受政治立场的转变有多快——下一段，小布什还说：‘我们将进一步推动医保可携带性，让员工换工作时无需担心健康保险。’这太疯狂了。如果你在奥巴马时代作为共和党人谈论跨雇主医保可携带性，四年后再提这个话题就会显得很危险。

Yeah. And just to give you a little look into how much the window changes of which side represents which party, The next paragraph, George w Bush also says, we will do more to make this coverage portable so workers can switch jobs without having to worry about their health insurance. I mean, it's crazy. If you're a Republican during the Obama era talking about having coverage that's portable across employers, that's a scary thing to be talking about just four years later.

是啊，真讽刺。

Yep. So funny.

所以当时政治风向开始变成：‘嘿，大家都想要完善的电子病历系统。理论上我们认为这会带来很多好处。’

So you're starting to get these political winds of, hey. Everyone wants a good system for electronic medical records. We think in the abstract, there'll be a lot of good that comes from it.

我认为背后还有更深层的动机。早在2006年，所有美国人都清楚现有医疗体系糟透了。没错它有好的一面，但总体上是成本失控、占GDP比重过高、效率极度低下。我们想尝试改变这种状况。

Well, I think there's an even deeper motivation than that. In 2006 already, I think everybody knows in America the current health care system sucks. Yes. There are great things about it, but overall, this is cost disease run rampant, huge portion of GDP, massively inefficient. We wanna try and fix it.

但在如何改革的问题上，我们并未达成共识。

How to fix it, we don't all agree on.

我们不知道具体该怎么改，但数字化医疗和推广电子病历的承诺，被视为能带领我们走出困境的解决方案。对吧？

How to fix it, we don't know, but this promise of digitizing it and incentivizing EMR adoption is held forth as a promise that can deliver us from this problem. Right.

这至少像是朝着正确方向迈出的一步。

It feels like a step in the right direction.

而当时全美仅有13%的医疗机构拥有电子健康记录系统。在2000年代中期，这完全是个数字化程度极低的行业。

And at the time, only 13% of health care facilities in America had an EHR system at all. This is a massively not digitized industry here in the mid two thousands.

不过我觉得13%这个数据存在争议。有人会说电子病历的定义后来改变了，所以实际拥有系统的机构远多于13%，但这是我们能获得的最佳数据了。

Which I think there's some pushback on that 13%. People would say, well, the definition of EHR just changed. So, actually, there were a lot more than 13% that had it, but that's the best data that we have is that.

有道理。

Fair enough.

好的。在我们讨论具体立法和事件之前，还有一个概念需要理解，那就是互操作性。因为每当提到EPIC或任何电子健康记录系统时，这个词就会出现，了解其分类很有必要。首先是第一种也是最简单的互操作性，即不同医院间Epic系统之间的互通。我想将我的病历从一家医院转移到另一家医院。

Okay. Now before we get to the actual legislation and what happened, there's one other concept to sort of have in your mind, which is interoperability. Because this word comes up every time EPIC comes up or any EHR comes up, and it's worth knowing sort of the buckets. So there's the first and easiest interoperability, which is Epic to Epic at a different hospital. I wanna transfer my records from one hospital to another.

他们也使用Epic系统。相同的技术应该能轻松实现传输。第二种是Epic系统与其他医院的不同电子病历系统互通——Epic与Cerner、Epic与Meditech、Epic与Allscripts、Epic与某些自制系统。你可以想象这其中技术难度更大的原因。

They also have Epic. It's the same technology that should transfer easily. Two is Epic to another EMR that's at a different hospital. Epic to Cerner, Epic to Meditech, Epic to Allscripts, Epic to some homeworld system. You can imagine the technical reasons why that would be harder.

它们的架构不同。可以说除了Meditech之外，其他系统都没有单一数据库，等等。

They have different architectures. All the other ones, arguably, except Meditech, don't have a single database, you know, etcetera.

而且这个行业的标准远不如SaaS软件或B2B软件模式那样统一。在讨论第三类之前，我们先思考下这里可能存在的利益动机。Epic系统内部传输没问题，很简单。但医院间传输——你要知道这些机构是竞争关系。

And standards have not been quite as standard in this industry as they are in SaaS software, easier b to b software mode. Now before we get to the third category, let's just think about some of the incentives that are probably at play here. Epic transferring to themselves, fine. Easy. A hospital transferring to a different hospital, you can imagine these places are competitors.

它们是企业。除非真正符合患者利益，否则可能不愿支持这种传输，不过至少会对此保持敏感。而Epic与其他医院的异源电子病历系统互通？不仅医院可能不愿意，Epic公司本身恐怕也不乐见。

They're businesses. They may not wanna support that unless it's really in the patient interest, but they're at least gonna be sensitive to it. Epic to another EMR at another hospital. Well, not only the hospitals maybe don't want that. Maybe Epic doesn't love that either.

没错。各方利益实际上都在阻碍这种情况发生。Epic不希望这样，医院也不希望这样。

Right. Interests are sort of aligned against this happening. Right. Epic doesn't want that, and the hospital doesn't want that.

虽然他们会给出很多冠冕堂皇的理由说'我们确实需要互通'，但坦白说，除了患者利益这个因素（毕竟我们都会在多家机构就医），Epic公司没有任何商业理由希望这种情况发生。然后就是第三类——Epic与想要使用其数据、基于其平台或与之互通的第三方应用程序的对接。多年来该公司对此一直极其谨慎。

And, you know, they talk about a lot of good reasons why, hey. Actually, we do want that, but let's just call a spade a spade and say there's no business reason why Epic would love for that to happen. Other than, of course, it's in the patient's interest, and everybody really should do what's in the patient's interest because we all get care from multiple places. Then there's this third category, Epic to third party application that wants to use data from Epic or sit on top of Epic or interoperate somehow with Epic. As a company, they have been very, very careful about this one over the years.

这很有道理。毕竟谁都不希望患者数据泄露。Epic曾公开表示他们从未发生过剑桥分析公司那种丑闻，正是因为对应用程序开发商的数据共享极其严格。但这也导致作为开发者，与Epic系统的整合难度远高于其他软件领域。

And for good reason. I mean, you don't want patient data to leak. Epic has publicly referenced the fact that they have never had a Cambridge Analytica situation because they're very, very careful about sharing data with other application developers. But the result of this is that it's been much harder to integrate with Epic as an application developer than you would be used to in any other software category.

是的。再次强调，这种情况的存在有非常正当的理由——我们处理的是受HIPAA保护的数据。不过也确实极大符合Epic的商业利益。

Yep. And, again, very justifiable reasons why that should be the case. We're dealing with HIPAA data here. Yep. But also massively in Epic's interest for that to be the case.

这种策略用起来相当便利。至于第一种Epic系统间互通的情景，其实非常出色。他们有个叫'随处护理'的功能，如今每天能交换2000万份患者记录。

It's very convenient as a strategy. Yes. So as for that first scenario, Epic to Epic, it's actually awesome. They have this thing called Care Everywhere. Today, there are 20,000,000 patient records exchanged daily.

我在准备这期节目时，用它整合了我在西雅图三家医疗系统中的所有MyChart账户。它运行得相当不错。关于它如何诞生并实现的故事非常精彩。朱迪亲自决定，Care Everywhere不应让客户挑三拣四——要么全面启用，要么彻底不用。一旦启用，就能与所有Epic客户互通，哪怕对方是本地竞争对手。

I used it as a part of prepping for this episode to join all my MyChart accounts across the three health systems I have in Seattle. It just seems to work pretty well. There's a great story of how it actually happened and how it came to be. Judy made the call personally that Care Everywhere wasn't a thing or shouldn't be a thing where their customers could pick and choose. If you were enabling it, it worked across all Epic customers, even if they were your local competitor.

故事是这样的：首批接受附带Care Everywhere功能新软件的客户中，有人在不自知的情况下同意了互操作性条款。他后来承认，如果意识到签署的合同包含这项内容，他本会拒绝。

And so here's the story. One of the first customers to accept that new software that came with Care Everywhere unknowingly agreed to the interoperability feature, and he later admitted that he would have declined it if he realized that it was included in the contract that he was signing.

没错。那位医疗系统的CEO后来确实承认了这一点。

Yeah. This is the CEO of that health system later admitted that. Yeah.

是那家医院的CEO。朱迪将Epic能推进此事归功于纯粹的运气。首战告捷后，他们便强制要求所有客户启用该功能，并为旧版本软件添加Care Everywhere支持。如今美国每家Epic客户都能与其他Epic机构共享数据，这也成了他们的宣传重点——

Of that hospital. And Judy described it as pure luck that Epic was actually able to move ahead. And so after that win, they then made it mandatory for all of their customers, and they retrofitted old versions of the software to support Care Everywhere. So every Epic customer in The US has it and can share with every other Epic customer in The US. So this is kinda their talking point of, hey.

我们其实拥有高度互操作性，推出的Care Everywhere功能时刻都在共享数百万条医疗记录。

Actually, we have lots of interoperability. We launched this thing called Care Everywhere. It shares millions and millions of records all the time.

对，他们总说我们是医疗数据共享领域的领头羊。

Yeah. They talk about, hey. We are the biggest sharer of medical record data of anybody.

正是。所以在2008年2月之前，Epic领域就带着这样的历史包袱：他们自认在用喜欢的方式实现高度互操作性。但说实话，当时几乎没有机构真正做好互操作性。我看过些医院管理者的访谈记录，他们说这个行业的互操作性简直可笑至极。除非迫不得已，否则没人愿意分享数据，何况操作本身也不简单。

Right. So coming into 02/2008, that's sort of the historical baggage that you should know about in Epic land of they believe they're doing a lot of interoperability in the way that they like to do it. Almost no one is great at interoperability. I saw some transcripts of talking with hospital administrators who were like, interoperability in this industry is just laughable, period. No one's incentivized to share with each other unless they absolutely have to, and it's not easy.

这些系统极其复杂，风险系数又高。

And these are incredibly complicated systems, and there's lots of risk.

有位首席信息官和我聊这个话题时打了个精妙比方：因为是患者健康数据，我们总觉得互操作性是理所应当的，数据就该随处可共享。我当然完全认同这点。

One CIO put it to me in a interesting way when I was chatting about this with him. Because it's patient data and health data, there's this sort of we feel like interoperability should be a thing. You should be able to share your data everywhere. I'm like, sure. Of course, you should.

我绝非否定这种理念。但他接着说：想象这是另一个行业，比如航空业。美联航会和达美航空共享客户数据吗？

I don't wanna discount that whatsoever. However, he was like, imagine this were a different industry. Imagine this were the airline industry. Does United share their customer data with Delta?

即使这样做对客户友好也不行吗？

Even though it's customer friendly to do so?

你知道吗，即便那是客户的数据？不行。当然不行。他们绝不会这么做。所以我乐意把病人的数据分享给街对面的竞争对手吗？

You know, even though it's the customer's data? No. Of course not. They never would. So do I feel great about sharing my patient's data with my competitor down the street?

不行。当然不行。

No. Of course not.

没错。这时你才能真正感受到矛盾。我相信你在听这段话时，情绪已经开始激动，因为你内心的资本家在想：这是生意，他们应该做对业务有利的事。而你作为社会一员、有着自身健康需求的人性面则在想：或许吧，但这事不该受资本主义阴暗面的支配。

Right. This is where you really start to feel the friction. I'm sure you're listening to this, and you're emotionally getting charged up at this point because you're feeling your inner capitalist think, well, it's a business. They should do the things that make sense for them as a business. And you're feeling your inner human being who is part of a society that has your own health needs thinking, well, maybe but this thing shouldn't be subject to the bad parts of capitalism.

或许这事该换个运作方式，商业利益主导一切让我觉得恶心。你应该感受到这种拉扯，因为这就是典型的双重困境。

Maybe this thing should function differently, and business interests it feels yucky to me that business interests are governing the way that things get done. You should feel that tension because this is one of those bothies.

这差不多描述了整个医疗行业的现状。没错。别搞错了——这绝对是个营利性行业。

Well, that kinda describes the whole health care industry. Right. Make no mistake. This is definitely a for profit industry.

是的。

Yes.

而且监管严格，还存在各种问题。

And it's highly regulated, and there's all these issues.

对。好了，我们进入正题。2008年2月，金融危机爆发。我们真该单独做期节目讲这场危机、崩盘、政府救助，以及我们如何避免国家乃至全球体系崩溃的奇迹。

Yep. Okay. So we're into the meat. 02/2008, the great financial crisis happens. At some point, we should just do a whole episode on the great financial crisis and the collapse and the government bailouts and how we managed to figure out how to not collapse as a nation and a global we pulled out of it, and it was amazing.

虽然花了些时间，但我们挺过来了。

Took some time, but we pulled out of it.

但就像疫情期间一样，摆脱困境的一个要素是政府表态说，好吧，我们需要

But one element of pulling out of it, just like during COVID, is the government said, alright. We need

经济刺激，伙计。

Stimulus, baby.

措施。我们需要经济刺激。我们需要能向经济砸钱的计划。

Stuff. We need stimulus. We need programs that we can throw money at the economy.

利率归零。到处撒钱。开动印钞机。想办法让人们从事生产性活动，并为此奖励他们。

Interest rates go to zero. Money out all over the place. Turn on the printers. Figure out how to get people doing productive stuff, and reward them for it.

既有零利率这样的货币政策手段，也有我们需要用直升机撒钱方式刺激经济的财政政策手段。

And there's the monetary policy stuff of interest rates to zero, but there's also the fiscal policy stuff of we need to helicopter money into the economy.

所以问题是当你准备用直升机撒钱时，可以给每个人寄支票。疫情期间就这么干过。

So the question is when you're gonna helicopter money into the economy, you could mail everyone checks. And that happened during COVID.

没错。这不是理想的做法。

Yep. Not a ideal way to do it.

更有效的做法可以追溯到平民保育团和罗斯福新政时期——我们要寻找‘准备就绪’的项目。哪些是我们都认同对国家有益且应该实施的好主意？让我们通过一些立法，用钱、用白给的钱重奖那些做我们认为正确事情的人。希望能实现双重效果：既完成资金分配这个基本目标，

A more productive thing to do that calls all the way back to the Civilian Conservation Corps and the FDR sort of New Deal era is we wanna look for shovel ready projects. What are things that we just kinda all agree on are good ideas for the country that should happen? And let's just pass some legislation that rewards the crap out of people with money, with free money, for doing the things that we think are a good idea anyway. The hope is you get this double whammy. You get the money distributed, which is just a goal.

又能创造就业机会，推动经济运转，同时完成一项公认的好事。天啊，眼前就有个‘准备就绪’的项目——电子病历。咱们干吧。想办法最终把这事情落实。

You're just trying to create jobs, trying to create economic motion, and you get something accomplished that is widely agreed upon to be a good idea. Oh my gosh. A shovel ready project right here, electronic medical records. Let's do it. Let's just figure out how to finally make that a thing.

所以目标有三个：第一，用财政刺激政策在大衰退后提振经济；第二，推广电子健康档案的采用；第三，促进实际使用——这与采用是不同的。

So the goals. One, fiscal stimulus to stimulate the economy after the Great Recession. Two, promote the adoption of electronic health records. Three, promote the use, which is different. The actual use

有意义的应用。

The meaningful use.

电子医疗记录的应用。我们不仅希望人们成为你们系统的用户而不登录，还希望他们经常登录并使用这些功能。并推动采用可互操作的标准，以便医疗服务提供者能在全国范围内共享患者数据。这些都是HITECH法案的目标。

Of electronic health care records. Not only do we want people to become users in your system that never log in, we want them logging in all the time using the stuff. And promote the adoption of interoperable standards so that providers could share patient data nationwide. These are the goals of the HITECH Act.

2009年的《经济与临床健康信息技术法案》。

The 2009 Health Information Technology for Economic and Clinical Health Act.

我很喜欢他们给这些东西起的名字。

I love how they name these things.

我知道。然后它被纳入近万亿美元的《美国复苏与再投资法案》。

I know. Which gets folded into the almost trillion dollar American Recovery and Reinvestment Act.

是的。具体机制是这样的。2009年法案通过时，有270亿美元直接用于激励实施电子病历的医院。如果包括更广泛的激励措施，其他健康IT项目、数据交换、培训等，总额实际上达到了360亿美元。这太不可思议了。

Yes. So the mechanics. In 2009 when the bill was passed, there is $27,000,000,000 available in direct incentive payments to hospitals that implemented electronic medical records. And if you include broader incentives, other health IT projects, data exchanges, training, the total actually comes to $36,000,000,000. This is amazing.

想象一下，如果你是一家软件初创公司，政府开始给你的客户寄支票，不仅因为他们注册成为客户并付钱给你，还因为他们实际使用你的软件而给他们更多钱。这对软件供应商来说是最好的事情。

Imagine if you're a software startup and the government just starts mailing checks to your customers, not only for signing up and becoming a customer and paying you money, but then paying them even more for actually using your software. It's like the best thing that could happen if you're a software vendor.

这就是政府去找你的客户说，嘿，我要给你钱，但这就像一张专用信用卡。你只能用这笔钱买这家软件初创公司的产品，而且必须买。买了之后还必须使用。如果你不买也不用，不仅拿不到钱，我还要处罚你，你得付钱给我。

This is the government going to your customers and saying, hey. I'm going to give you money, but it's like a dedicated use credit card. The only thing you can use this money for, and you must use this money for, is to buy this software startups products. And then you must also use them. And if you don't buy it and you don't use it, not only are you not gonna get the money, I'm going to penalize, and you're gonna have to pay me money.

是的。胡萝卜加大棒。具体来说，几年内每位医生采用该系统可获得4.4万到6.4万美元的激励金。这笔钱实际上是给医院的，但基本上是根据有多少医生这样做来支付。

Yes. Carrot and stick. So specifically, it amounted to 44,000 to $64,000 per physician in incentive payments over a few years for adopting it. Now that actually went to the hospital, but it's basically you get paid for how many physicians are doing this.

是啊。想象一下像凯撒这样拥有1.1万名医生的大型系统。那可是很多钱。

Yeah. So imagine a huge system like Kaiser with 11,000 physicians. It's a lot of money.

是的。高科技法案中包含了‘有意义使用’这个短语，这是个疯狂的术语——在这个行业里，只要提到‘有意义使用’甚至缩写‘MU’，就会触发敏感神经。最初‘有意义使用’是作为胡萝卜政策，后来变成了大棒。正如大卫你所说，刺激资金耗尽后约五年，医疗机构若未能有效运用如电子健康记录（EHR）这类健康IT软件，将面临重大经济处罚。凯撒家庭基金会（KFF）有篇题为《千次点击致死》的文章对此有段引述。

Yes. High-tech contained the phrase meaningful use, which is this crazy phrase where if you say meaningful use or you even say MU to anyone, it is a triggering term in this industry. First meaningful use was a carrot and then as a stick. So after the stimulus ran out, David, as you were saying, after about five years, health systems would face meaningful financial penalties for not meaningfully using health IT software like EHRs. There's a, KFF article entitled death by a thousand clicks that has a quote on this.

当时规模仅20亿美元的EHR供应商群体虽抱怨繁复的要求，但面对政府360亿美元的注资诱惑仍趋之若鹜。正如EHR供应商NextGen Healthcare（Epic十大竞争对手之一）的CEO鲁斯蒂·弗兰斯所言：‘整个行业的心态就像——眼前晃着这张支票，我只需勾选这些框就能拿到。那当然要干啊。’对于那些认为Epic是最大赢家的人，没错，这显然对其非常有利。但他们也不得不通过层层关卡确保产品完全符合法案奖励标准。

The EHR vendor community, then a scrappy $2,000,000,000 industry, griped at the litany of requirements but stood to gain so much from the government's $36,000,000,000 injection that it jumped in line. As Rusty France, CEO of EHR vendor NextGen Healthcare put it, and NextGen is one of the top 10 epic competitors, the industry was like, I've got this check dangling in front of me, and I have to check these boxes to get there. And so, yeah, I'm gonna do that. For everyone that wants to just think this was the most amazing thing ever for Epic, yes, it was obviously net very good. They had to do a bunch of hoop jumping through to make sure that it was exactly the thing that the bill was gonna reward.

业内每家公司都不得不投入大量开发时间，重新调整优先级，确保产品完全符合高科技法案的要求。

And everybody in this industry had to make sure that they spent a bunch of development time and a bunch of reprioritization in the company to make sure that it was exactly the thing that high-tech was saying that it needed to be.

没错。事情比‘这对Epic特别有利’更微妙。当然Epic获益巨大，但本质上这是对整个电子病历行业的利好。行业内的竞争动态完全是另一个维度的问题。

Yep. It's more nuanced than this is really good for Epic. Of course, it was really good for Epic. But, really, it's that this was really good for the entire EMR industry. The competitive dynamics within the industry are almost like a separate kind of question.

好吧。那谁受益最大？大概是最可靠的那个。如果医院原本没打算上EHR系统，现在眼前突然晃着这张补贴支票，我肯定选那个100%能无缝对接的系统——绝不冒险。

Well okay. So who's it gonna benefit the most? Probably the most reliable one. If I wasn't gonna do this before and now I just have a check dangling in front of me as a hospital to implement an EHR, I want the one with the integration that's a 100% gonna work. I'm taking no risk.

而且Epic那个系统，我记得有人说过很贵？但现在反正免费了，贵不贵无所谓，直接买最好的就是了。

And, also, that Epic one, I think someone told me before that was an expensive one. Well, I guess it doesn't matter that it's expensive anymore because it's free. So I'm just gonna buy the good one.

对，实质上就是免费的。

Yeah. Right. It's effectively free.

所以Epic作为高价位、高价值、最低风险的可靠供应商，自然成为最大赢家。

So Epic, by being the high price, high value vendor and the one that you could count on working with the lowest risk, they were gonna win in this situation.

精辟。就像用刺激资金买包，你可以选Target的平价款，也可以选爱马仕铂金包——反正都免费。

Yeah. That's a great point. It's like you're getting a stimulus to buy a handbag, and you could get the Target one or you could get the Birkin bag, and they're all free.

虽不完全贴切，但差不多是这个意思。有趣的是这本质上奖励了最可靠的软件，而非最具创新性的。在这种情境下你不敢冒险，因为只有系统真正落地并实现‘有意义使用’才能获得奖励。所以最终大家都会选择那个‘保证能用’的方案。那么高科技法案实际产生了什么效果？我们接下来逐条分析其目标。

And it's not exactly like that, but it rounds to that. It also is interesting because it basically rewards the most reliable software, not necessarily You end up not taking any risk in situations like this because you're not gonna get rewarded unless you actually stand the system up and then start getting meaningful use. So you end up with the one that's just going to work. So what did high-tech actually do? We'll go through sort of each of the goals.

它是否加速了使用率？绝对是的。电子病历的市场渗透率从2009年的9%医院覆盖率飙升至2014年的95%。这太疯狂了。大卫，你还听说过哪个市场能在五年内实现从几乎无人使用到几乎人人使用的飞跃？

Did it accelerate usage? Absolutely. Market penetration of electronic health care records went from 9% of hospitals in 2009 to 95% by 2014. That's insane. David, what other markets have you ever heard of that saw usage go from almost nobody to almost everybody in five years?

疫情期间某些类别的软件。

Certain categories of software during the pandemic.

没错。这是个很好的观点。

Yeah. That's a good point.

我猜疫情期间的Zoom可能是最接近的例子。

I would imagine maybe Zoom during the pandemic is the closest thing.

想象一下此刻作为Epic员工的感受——突然间你们的产品对所有潜在客户都免费开放了。这太不可思议了。数字化对患者来说是巨大的进步，尽管很多医生会抱怨。能够像我们讨论MyChart时说的那样，给医生发消息咨询问题并随时调取自己的电子病历，这简直太棒了。

I mean, to be an Epic employee at this moment where suddenly your category is just free for all your potential customers. It's crazy. And digitization was great for patients even though, like, a lot of doctors will complain about it. It is totally amazing to be able to message your doctor about something and pull up your own records electronically as we talked about with MyChart.

自主预约就诊。没错。所有这些功能。管理全家人的医疗。

Schedule your own appointments. Yep. All of the above. Manage your family's care.

是的。完全正确。好，那么下一个目标：降低成本。关于电子病历是否普遍降低费用，统计数据有两面性。

Yes. Absolutely. Okay. So then the next goal, cost reduction. There are stats both ways on if EHRs generally reduce costs.

我们发现一项统计称医院成本因电子病历的实施降低了10%。但也有观点认为，电子病历的采用可能反而加速了不必要的医疗检查，并提高了相同诊疗项目的收费编码——要么增加编码数量，要么提高编码金额。这就是关于'是否降低系统成本'的反方论点。电子病历的批评者认为，同样的诊疗过程中，现在从诊室开出的检查项目比过去多得多。坦白说，这正是医院购买电子病历系统的目的之一。

We found one stat that claimed that costs in hospitals went down by 10% with the introduction of EHRs. There's also arguments that the adoption of EHRs may actually have accelerated the ordering of unnecessary care as well as increased billing codes for either more codes or higher dollar codes for the same procedures. So that's sort of the counterargument to did it decrease cost in the system? The critics of EHRs say that basically more stuff is getting ordered from exam rooms for the exact same procedures than was happening before. And frankly, that's the goal of of hospital buying an EHR.

某种程度上说，这就是收入最大化。

I mean, part of it is revenue maximization.

没错。再说一次，这些都是商业实体。明白吗？尽管其中许多可能是非营利组织或大学体系的一部分。归根结底，这是由医院产生的收入，医院有管理团队，主要员工是喜欢赚钱的医生和护士。

Right. Again, these are commercial entities. You know? Even though many of them may be nonprofit organizations or part of a university system or what have you. At the end of the day, this is revenue being generated by a hospital with a management team and with its primary staff being doctors and nurses who like to make money.

人们去医学院成为医生或护士的原因是为了获得一份好工作，过上优渥的生活。

The reason you go to medical school to be a doctor or a nurse is to get a good job and make a good living.

还有职业声望的因素，你想帮助他人，但这确实是个高薪职业。没错。有篇很棒的文章叫《史诗级反乌托邦》，不过我得说这篇文章呈现的视角有些片面。

And the prestige of it, and you wanna help people, but it's a high paying job. Yep. So there's a great read called an epic dystopia. And I will say this article presents kind of a one-sided view of things.

这是《美国展望》杂志那篇文章吗？

This is the American Prospect article?

对。但里面有段引述：比如有位医生提到，她的主管经常联系她说'那次预约算二级，你不觉得可能是三级吗？'显然这里三级能比二级向保险公司收取更多费用。

Yep. But there's a quote. One doctor, for example, stated her supervisor regularly contacted her and said something like, that appointment was a two. Don't you think it might be a three? And obviously, in this case, a three could bill more to insurance than a two.

还有人告诉我'如果你做了X，那次预约几乎肯定也做了Y。如果用那些代码，你可以收取更多费用。'如果有电子系统，相比没有系统的情况，你更可能为更多项目收费。这就是反对大规模实施电子健康记录能节省系统成本的反方论点。

Or someone else gave me a quote, hey, if you did x, almost certainly you did y in that appointment. If you use those codes, you could charge more. And if you have a system, a computer system versus not having one, it's more likely that you are billing for more stuff. That would be the counterargument to this mass implementation of EHRs saving costs for the system. Yep.

数据互通性？基本没有。立法对'有意义使用'有明确规定，但对人们讨论的数据标准却未作硬性要求。这是立法的目标，但不像'有意义使用'那样设有数据互通的激励措施。

Data interoperability? Not really. The legislation was prescriptive about meaningful use. It really wasn't prescriptive about data standards that people talked about. That's a goal of the legislation, but it's not like there were incentives for data interoperability the way there were for meaningful use.

人们总是追逐激励。数据互通并未真正实现，这对Epic非常有利——他们拥有自成体系的系统，不需要与其他系统集成就能使软件套件发挥作用。作为行业龙头且能独立完成所有功能的公司，他们不需要互通性，这也没有明确奖励机制，所以客户也不优先考虑这点。

And so people follow incentives. The data interoperability did not really happen, which was very convenient for Epic who had a whole system that they made themselves, and they didn't really need to integrate with anyone to make the software suite useful. So again, as the leading player in the industry and the one that can kinda do everything themselves, they didn't need interoperability, and it wasn't explicitly rewarded. So customers didn't prioritize it either.

确实存在让Epic易受批评的事实：朱迪在整个过程中都担任奥巴马政府健康信息技术委员会的成员，该委员会为《HITECH法案》提供建议。

And there is a fact pattern that opens Epic up certainly to criticism here, which is that Judy was on Obama's health IT council through all of this, which was advising the Obama administration on the HITECH Act.

其他竞争对手也有人在不同委员会任职。她并非政府中唯一有话语权的人。

And other competitors had people on other committees too. It's not like she was the only one with a voice in government.

没错。我正想说这个常被忽略的便利事实——所有竞争对手如塞纳、Allscripts等也都参与了那些委员会。

Right. I was gonna say that is a convenient fact that gets left out by a lot of people making that argument or that all the competitors, Cerner, Allscripts, etcetera, they were all on those councils too.

是的。但我们先看看数据互操作性这件事。它当时没实现，但十五年后现在正逐渐普及。至少我们有了数字化记录的基础，这样在推动互操作性时，没有可操作性就无法实现互操作性。

Yep. But let's just look at the data interoperability thing. It didn't happen, but it's happening more now, fifteen years later. So And at least we have the foundation of digital records so that as pushes and shoves happen to make it more interoperable, without operability, you can't have interoperability.

我认为这就是我对《HITECH法案》和'有意义使用'的理解，至少在电子病历行业是这样。每当政府介入并扭曲市场时，就会出现奇怪的现象。尤其是当政府开始规范产品开发和使用方式时，市场会变得一团糟。

And I think for me, that's kinda my takeaway of the HITECH Act and Meaningful Use here, at least when it comes to the industry of EHRs. Yeah. Anytime you've got government coming in and distorting a market, you're gonna get weird stuff happening. And especially anytime you have government coming in and regulating how products are to be developed and used Yes. In a market, you're gonna get really messy stuff happening.

好的。这里产生了两个严重的副作用：第一，国会通过定义'有意义使用'，不仅意外设计了软件功能规格，还无意中规定了医生的行医方式。现在医生们被迫点击一堆以前根本不需要点的选项——有些是医院系统实施不当，有些是软件过于复杂，但更多只是为了确保...

Okay. So there were two really bad side effects here. One, by literally defining what is meaningful use, Congress not only accidentally designed the software and specified the features, but they also accidentally told doctors how they needed to do their jobs. And so doctors are, like, running around now clicking nine things that they never needed to click before, some of which are poor implementation by their hospital system, some of which is because the software is really complex. But a lot of it is, like, just making sure that

这是立法要求的。

This is what the legislation requires.

没错。符合'有意义使用'标准，医院才不会被处以经济处罚。

Yes. Complies with meaningful use so that the hospital then doesn't come and get hit with a financial penalty.

是啊，我觉得这算是'有意义使用'最糟糕的方面了。

Yeah. This is sort of the most unfortunate aspect of meaningful use, I think.

我认为只能排第二。最严重的是它永久性增加了医疗实践的监管负担。即便刺激计划结束，医院仍要面对各种强制字段和工作流程。这整体提高了行业的运营成本，现在大家只求合法满足'有意义使用'定义，而非真正帮助医患双方。

I think it's the second most. I think the biggest one is they increase the regulatory burden of practicing medicine, period. So now since hospitals can face big financial penalties, there's all these mandatory fields and workflows everywhere forever even after the stimulus runs out. And so it just generally increased the operational overhead of the whole industry. The thing to optimize for now is hitting the MU definitions legally rather than the spirit, which is help doctors and patients get more out of the system.

最终导致医疗系统间加速兼并（虽然这是既有趋势），因为运营成本更高了。整个系统充斥着更多行政负担、繁文缛节和资源浪费。

And you end up with things like health systems merging with other health systems because the cost of doing business is higher, which is a preexisting trend, but it's certainly an accelerant. There's more overhead, more burdensome regulation, just more crap in the system, more waste.

这些无疑都是弊端。但反过来说，替代方案是什么？退回到纸质系统吗？那更糟。至少现在我们实现了数字化普及。

So all that unquestionably bad. At the same time, what's the alternative? We're be in the paper based system? Like, that's not good. At least we have adoption here.

很多人确实用'至少实现了普及'来为此开脱。数字化确实更好，但这是最优的数字化形式吗？不是。但整体而言数字化是好事吗？

At least we have adoption here is what a lot of people have sort of chalked this up to. It's definitely better to be digital. Is this the best form of digitization that could have happened? No. Is digitization overall good?

是的。

Yes.

我认为如果把视角拉得极其宏观，最大的功劳应该归于政府和立法者，是他们创造了这一切。当初的目标真的是为了创造就业机会和刺激国家经济吗？如果这是目标，那算是加分项。因为这个政策确实催生了许多工作岗位。

And I think if you zoom way, way, way out, you give the most credit to the government and the legislators who created all of this. Was the goal actually a jobs program and an economic stimulus for the country? If that was the goal, a plus. Lot of jobs got created because of this.

我国18%的GDP就业岗位来自这个领域。所以无论好坏，医疗从业者已成为我们社会的重要组成部分。

18% of our GDP's worth of jobs are in this field. So it's now a huge part of our society as people who work in medicine for better or for worse.

还有医疗相关领域，比如医院里的IT管理员、EPIC系统管理员等。这些不仅提供了大量岗位，而且是优质工作。再往前看，这些都是美国本土职位，不依赖进口或制造业，为国内许多人创造了稳定优质的职业道路。从政策角度来看，或许不算糟糕。

And related fields to medicine, like IT administrators, you know, EPIC administrators at hospitals. These are a lot of jobs, and these are a lot of good jobs. And play it one step forward. These are all domestic American jobs, not dependent on imports, not dependent on manufacturing, that have created viable, great career paths for a lot of people in this country. From a policy standpoint, like, maybe not bad.

是啊。但我讨厌这样，大卫。

Yeah. I hate it, David.

哦，我并不是说我喜欢就业计划这个概念。我只是说，如果从政府实施这个政策的宏观目标来看，他们成功了吗？如果那是目标，他们确实成功了。

Oh, I'm not saying I love the idea of jobs programs. I'm just saying if you zoom way out of what was the goal of government in doing this, did they succeed? If that was the goal, they succeeded.

没错。在那个急需经济刺激的时期，这样做确实有益。但政府应该长期用纳税人的钱来扶持行业，并在这些行业中创造和维持大量工作岗位吗？不，绝对不应该。

Yeah. It was good to create fiscal stimulus for that period of time where we really needed it. Should the government be in the business on a durable basis of using taxpayer funds to prop up industries and create and maintain a bunch of jobs in those industries? No. Absolutely not.

所以你设定的标准很低。它刺激经济了吗？我是说，寄支票也能刺激经济。我认为这确实刺激了经济，还附赠了个免费优惠券——我们获得了某种程度的电子病历系统。尽管这些系统不能互操作，也不是我们国家理想中的最佳系统，但总比没有强，而且基本上是随着经济刺激计划白送的。

And so it's a very low bar, what you're saying. Did it stimulate the economy? I mean, mailing checks would have stimulated the economy. I look at this as like, yes, it stimulated the economy, and it had the free stapled coupon of we got some amount of electronic medical records. Even though they're not interoperable and even it's not the best system we possibly could hope for as a country, it's a better one than we would have had otherwise, and it kinda came for free with the stimulus checks.

对。让我们回到EPIC的故事上来。

Yep. So back to the epic story here.

好。那么'有意义使用'政策为它们带来了什么？有趣的是，如果你退一步想：政府花钱让整个行业采用新事物的副产品是什么？本质上你是在把未来提前，认为这一切终将发生，而我们希望它现在就发生。

Yeah. So what did Meaningful Use do for them? Well, interestingly, if you just take a step back and say, what is the byproduct of the government paying off a whole industry to adopt something new? What What you're basically doing is pulling forward the future and saying, this was all gonna happen eventually. We wanna make it all happen right now.

需要明确的是，我认为特别是在Kaiser获胜后，即便没有实质性应用，Epic也注定会成为主导者。他们已经开始在竞争中横扫千军了。

And to be clear, I think, especially after the Kaiser win, Epic was going to become the dominant player anyway, absent of meaningful use. They were starting to run the table on competition.

所以问题就在这里。他们当时正要崛起。但当你向这个问题投入360亿美元时，你实际上是在宣告：我们要对任何可能在此之后成为主导者的竞争者关上大门。我们现在面对的就是现有的竞争格局，而我们觉得现有格局已经足够好。这个方案准备得如此充分，我们希望最优方案能在各地实施。

So that's the question. They were starting to. But what you definitely do when you throw $36,000,000,000 at the problem is you say, we're gonna close the door on anyone that might become a dominant player after this. The current competitive set is now what we're dealing with, and we think the current competitive set is good enough. This is shovel ready enough that we want the best ones to get implemented everywhere.

这些制度将固化数十年之久。确实如此。

These are stuck in there for multiple decades. So Yeah.

这里的转换成本极其高昂。

The switching cost here is enormous.

没错。这是个公平的权衡。我甚至不认为他们通过这项立法时是有意为之，但事实就是：那些理论上更具创新性的新型电子健康记录系统，本可能在高科技之后出现，但现在至少很长时间内都不会实现了。

Yes. And that's a fair trade off. I don't even think it was that intentional of a trade off that they made by passing this legislation, but it is definitely true that a new EHR that may have been more theoretically innovative in some way that could have come after high-tech wasn't going to happen, at least for a long time.

是的。因为你将大量招标流程集中到了一个时间点。多数机构选择了Epic——这本就是大概率事件——但原本这些流程会分散在未来进行，那时可能出现其他竞争者。

Yep. Because you pulled forward so many RFP processes to a single point in time. Yes. And the majority of them chose Epic, which they probably would have anyway, but a lot of those processes would have happened in the future at which point in time other competitors may have emerged.

对。那些理论上未来可能出现的创新竞争者，根本没有机会在空白领域竞标——所有人都在与你现有系统竞争。我认同这点。但这有点吹毛求疵了，对吧？

Right. There's no greenfield bidding for those theoretical future innovative competitors that everyone's bidding against your current system. I buy that. But that's kinda nitpicky. Right?

这有点像在问：我们究竟在为谁敞开大门？如果你想寻找监管俘获的确凿证据，我认为更准确的描述应该是监管顺风而非监管俘获。我不认为Epic的人对此感到欣喜。我的印象是他们本以为自己能自然占领这个市场，现在却不得不以这种拼凑的方式实现。

It's a little bit of, like, a for whom are we holding the door open. So if you're looking for a smoking gun on regulatory capture, I think the right way to characterize this is as regulatory tailwind rather than regulatory capture. I don't think the folks at Epic loved it either. My impression is they felt like they were going to take this market, and now they had to do it in sort of this Frankenstein style way.

这绝对让产品变得更糟了。

Well, it definitely made the product worse.

是啊。产品质量下降了。所有人的负担都加重了。你知道，这也让他们更确定能赢得市场——因为如果某件事五年后可能发生，或者现在就能发生，你当然选择立即确定的结果。但他们肯定不喜欢...

Yeah. It made the product worse. It increased burdens for everyone. You know, it made it more sure that they were gonna win the market because if something's gonna happen five years from now or it could happen now, you'd rather happen now, and it be certain. But they certainly don't love

医生每次看诊需要勾选57个复选框。

it that doctors have to check 57 boxes on every patient visit.

没错。所有这些合规负担，加上软件一旦被立法强制使用就变得极其难用。是啊，通过立法来推动产品开发，这...

Right. So all this compliance burden and the software being frankly hard to use once it's Legislated. Yeah. Product development by legislation, which to be

需要澄清的是不仅Epic系统如此，所有电子病历系统都这样。

clear isn't just Epic. It's all of them.

还有这种规模软件的复杂性，涉及如此多不同界面和参与者等等。一个重要批评是它挤占了诊疗时间。2016年研究显示，医生在电子病历系统录入数据的时间与直接诊疗时间达到2:1。其他研究也指出医生现在每天工作11-12小时，不断回复消息——这又是医院管理方式的问题。

And also just the complexity of software of this magnitude with this many different screens and participants and all that. A big criticism is that it takes time away from patients. There was a 2016 study that showed that entering data into EHRs consumes about two hours of doctor time for every one hour spent providing hands on patient care. There's all this other research around doctors now work eleven, twelve hours a day. They're, like, constantly responding to messages, which, again, is a hospital configuration thing.

其实可以建立消息分诊机制。

There's a way to triage messages.

《高科技法案》和'有意义使用'政策的另一个弊端是：在医疗活动数字化并全部移入电子病历系统前，许多规定未必被严格执行，这对医院反而更有利。比如开处方药或检查单本该由医生亲自操作，但在纸质时代，医生常让助理代劳。若每天接诊20名患者且多数需要检查或药物，医生只需说'助理你来处理'，这些工作就能在白天完成。

Another downside to the High-tech Act and Meaningful Use is that before digitization and moving all this activity from hospitals into the EHR, there were a lot of regulations and guidelines that maybe weren't always followed, and that was sort of for the best in the hospital. So things like it's supposed to be doctors themselves who put in orders for pharmacy for meds or for scans or stuff like that. But in the old world, before everything moved into the EHR, doctors were supposed to do it, but they would have their medical assistants do it. If you're seeing 20 patients a day and a whole bunch of them need scans or meds or whatever, you can just be like, hey, medical assistant. Do all this, and they can do it during the day.

对，我稍后再统一签字。

Yeah. I'll sign them all later.

正是。但数字化后所有操作都在电子病历系统中留痕，规则就必须严格执行。这意味着医生突然失去了过去那种系统内的弹性协助空间。

Exactly. But now once everything's digitized and in the EHR, that means that the rules have to be followed because they're tracked. Right? And so that means that all of a sudden, doctors don't have as much help in Slack in the system as they used to.

有意思。这正是导致医生职业倦怠的因素之一。不过确实需要对比过去的情况。

Yeah. That's interesting. So this is the sort of thing that ends up contributing to doctor burnout. Yep. But you do have to compare it to how it used to be.

1970年有项经典研究显示，管理纸质病历等沟通活动占医院总运营成本的35%-39%。这不包括医生时间成本，但在纸质时代，这始终是医院巨大的时间和金钱消耗。

There's a great old study from 1970 that found that communications activities, such as managing physical records, accounted for 35 to 39% of total hospital operating costs. That's not the doctor's time, but especially in the paper world, it was always a huge amount of cost and time from the hospital.

没错。你这是在稍微转移这方面的负担，并通过所有有意义的使用法规创造了更多负担，但这不是一个新问题。

Right. You're shifting around the burden of this a little bit and creating more burden through all the meaningful use regulations, but this is not a new problem.

你知道还有谁不喜欢这样吗？2017年，奥巴马本人告诉Vox，他认为高科技立法没有达到他的期望。这是他的原话：‘事实是仍有堆积如山的文书工作，医生仍需输入资料，护士们把所有时间都花在这些行政事务上。我们投入了大量资金试图鼓励所有人数字化，赶上世界其他地区，但这比我们预期的要困难。’

You know who else doesn't love it? So in 2017, Obama himself told Vox that he felt that the high-tech legislation did not live up to what he wanted. And here's his quote. The fact that there are still just mountains of paperwork, and the doctors still have to input stuff, and the nurses are spending all their time on this administrative work. We put a big slug of money into trying to encourage everyone to digitize, to catch up with the rest of the world, and that's been harder than we expected.

实际上，我认为这段话根本不是在说我们要在数字化方面赶上世界其他地区。我认为我们曾是这方面的领导者。但如果希望我们能以某种方式降低成本与世界接轨，那本会很棒，但这并未发生。

The quote, I actually don't think it was at all about catching up with the rest of the world on digitization. I think we were a leader there. But if the hope was that we could somehow downgrade our costs to be in line with the rest of the world, that would have been great, and that did not happen.

是的。我采访过的一位CIO对此有个精彩的说法。他说‘有意义使用’和高科技法案在行业数字化方面取得了巨大成功，但对行业的数字化转型却毫无作用。我们实现了数字化，但并未以人们乐观期待的方式实现转型。

Yep. One of the CIOs I talked to had a great quote on this. He said that meaningful use and the high-tech act wildly succeeded at digitization of the industry. It did absolutely nothing on digital transformation of the industry. We digitized, but we didn't transform in the way that I think people were optimistically hoping for.

这很有趣。好消息是这仍可能实现。既然所有记录都已数字化

That's interesting. And the good news is that can still come. Now that all the records are digital

是的。既然我们已经数字化了，没错。

Yes. Now that we've digitized, yes.

你现在确实可以对数据做些以前做不到的有趣事情。

You actually can do interesting things with the data that you couldn't have done before.

我们稍后会在几分钟内讲到故事结尾时讨论AI——至少目前看来——以及环境AI的承诺，它们能让许多这类繁琐流程对人类消失。是的。在这背景下，Epic继续史诗般地获胜。2011年，他们收入达到10亿美元，持续赢得所有大型系统的RFP竞标。

And we'll talk about when we get to the end of the story in a couple minutes, the promise, at least right now, of AI and ambient AI in making a lot of this onerous process just disappear for humans. Yes. So on the back of all of this, Epic continues to win epically. In 2011, they hit a billion dollars in revenue. They keep winning all the big systems that come up for RFP.

约翰霍普金斯、西达赛奈医疗中心、加州大学旧金山分校等等，名单长得数不完。对Epic的竞争对手而言，合并与整合始终在发生。但随着‘有意义使用’的实施，整合真正加速了——这再次只会对Epic有利，因为该领域的整合意味着系统变得更复杂，整套方案协同性下降，Epic的优势反而更加凸显。2008年2月，Allscripts与MySys合并。

Johns Hopkins, Cedars Sinai, UCSF, list goes on and on and on. For Epic's competitors, they had always been merging and consolidation had always been happening. But now with Meaningful Use being in place, consolidation really picks up, which, again, all of which is just gonna accrue to Epic's advantage because consolidation in this space means the get more complex. They don't work as well altogether as a suite, and Epic's advantage just becomes all the more pronounced. So 02/2008, Allscripts merges with MySys.

2010年2月，新Allscripts实体又与Eclipsis合并。他们不断收购更小的玩家。如今这家公司叫Veradigm。2011年，Meditech收购LSS数据系统。然后在2014年8月，我们之前提到过的一桩重大并购发生了。

02/2010, that new Allscripts entity then merges again with Eclipsis. They keep on acquiring more smaller players. Today, that company is called Veradigm. 2011, Meditech acquires LSS Data Systems. And then in August 2014, one of the big ones that we've already alluded to happens.

Cerner以13亿美元收购西门子医疗。

Cerner buys Siemens Health for $1,300,000,000.

这标志着Cerner开始走下坡路。这是我的理解。

Which that starts the downward spiral for Cerner. That's my understanding.

是的。我在研究中听说，即使在2025年的今天，客户仍会自称是西门子客户或Cerner客户。系统仍未完全整合。

Yes. I heard in the research that even today in 2025, customers will still refer to themselves as either Siemens customers or Cerner customers. It's still not fully integrated.

与此同时，我认为在甲骨文收购后，他们正试图全面重写系统。

Meanwhile, I think post Oracle acquisition, Oracle's trying to rewrite it all anyway.

没错。而且进展并不顺利，这点我们稍后会谈到。

Right. And that's, not going well, which we'll come to later.

是的。所以

Yep. So

这直接把我们引向了国防部的合同。

this leads us right into the Department of Defense contract.

如果你是电子病历公司，这就是千载难逢的机遇。

The motherload of all opportunities if you are an EMR.

VA合同。天啊。对某些人是千载难逢的机遇，对美国纳税人来说却是政府浪费的典型代表。没错。在美国。但在讲那个故事前，我们有些更积极的好消息要告诉大家。

VA contract. Oh, boy. The motherload of all opportunities, or if you are an American taxpayer, the motherload of everything that is wrong with governmental waste Yep. In America. But before we get into that story, we have some happier and better news to tell you.

是的。首先要感谢节目的长期赞助商Crusoe。

Yes. And that is to thank longtime friends of the show, Crusoe.

是的。感谢克鲁索为我们带来片刻轻松，以及对未来充满兴奋与乐观的展望。克鲁索并非传统平台，他们正从根本上重新构想AI基础设施的实体建设方式。

Yes. Thank you, Crusoe, for giving us a moment of levity here and a moment of excitement and optimism looking to the future. Crusoe is not platform. They are actually reimagining how AI infrastructure gets physically built from the ground up.

没错。我们曾讨论过克鲁索利用闲置能源为GPU数据中心供电的气候友好方案。但其真正独特之处在于，他们是完全垂直整合的AI基础设施企业。创始人蔡斯和库利很早就意识到，要成为最佳AI云平台，必须构建从能源获取、数据中心建设到最终提供AI云服务的完整技术栈。

Yep. In the past, we've talked about Crusoe's climate aligned approach powering their GPU data centers with stranded energy. But what's truly unique about Crusoe is that they're a fully vertically integrated AI infrastructure business. So Crusoe's founders Chase and Culley realized early on that in order to become the best AI cloud platform, you actually need to build the entire stack from sourcing the energy to building the data centers and ultimately providing the end AI cloud service layer.

最佳例证就是他们正在德州阿比林建造的1.2吉瓦特巨型AI数据中心。2024年6月才在空地上破土动工，如今不到一年就将启用首批建筑。对行业而言，这种规模的新增产能建设速度堪称疯狂。

So the best example of this is the giant 1.2 gigawatt AI data center that they are building in Abilene, Texas. They broke ground in just June 2024 on an empty field, and now within a year, they are about to turn on the first few buildings. Bringing on new capacity of this size in less than a year is crazy fast for the industry.

没错。用数据说明：当今北弗吉尼亚所有数据中心总容量——全球70%互联网流量经此——仅4.5吉瓦特。克鲁索在阿比林的单个AI工厂就超过当今互联网核心供电区四分之一规模，而这只是他们其中一处基地。

Yep. And to put that 1.2 gigawatts in perspective, if you take the entire data center capacity located in Northern Virginia today, so where, like, 70% of the world's Internet traffic flows through, all of that is only 4.5 gigawatts. So Crusoe's single AI factory in Abilene will be more than a quarter the size of what powers a huge portion of the Internet today, and that's just one of their locations.

是的。克鲁索承担了构建实体AI能力的全部复杂工作，让客户只需专注创新而非基建。他们刚宣布两项新服务：托管推理服务免除开发者管理服务器之苦，自动集群服务消除模型训练的运维负担。

Yeah. Crusoe handles all of the incredible complexity of building physical AI capacity so that their customers can just focus on innovation, not infrastructure. And they just announced two new services to do that. Their managed inference service frees developers from managing servers, and their auto cluster service eliminates the operational burden of model training.

正是。因此考虑AI工作负载部署时，请务必评估克鲁索。因其在物理技术栈各层级均实现运营创新，克鲁索能提供无与伦比的性价比、上市速度及长期可靠的平台。这家卓越企业近期融资轮吸引了NVIDIA、创始人基金等顶级投资方，本与我也荣幸参与其中。

Yep. So when you're thinking about where to run your AI workloads, make sure you consider Crusoe. Because they operate and innovate at every single layer of the physical stack, Crusoe delivers unmatched price to performance, speed to market, and a platform that customers can rely on for years to come. It's an incredible company, and Ben and I are excited to be investors in their recent funding ground alongside NVIDIA, Founders Fund, and a whole slate of other great investors too.

确实如此。了解更多请访问crusoe.ai/acquired，或点击节目备注链接。联系时只需告知是本和大卫推荐即可。好的大卫。

That we are. To learn more, head on over to crusoe.ai/acquired. Crus0e.ai/acquired, or click the link in the show notes. And when you get in touch, just tell them that Ben and David sent you. Okay, David.

国防部的败笔。

The DOD debacle.

2015年国防部败笔。当时国防部决定为全军医疗机构招标全球电子健康记录系统。最初仅覆盖现役军人（与后来的退伍军人事务部系统分开），这份合约直至当时仍是医疗IT史上最大标案，最终价值43亿美元——甚至超过凯撒医疗项目。

The 2015 DOD debacle. So the Department of Defense decides that they're gonna bid out a global EHR contract for all of their hospital and health care across all branches of the military. Now this is, at the beginning, just active duty US military, so separate from the VA system, which comes later, the Veterans Administration, all the veterans of the US military. This deal in 2015 is, up until this moment in time, the biggest health care IT contract of all time. It ends up being a $4,300,000,000 deal, so even bigger than the Kaiser deal.

该记录保持两年后，被退伍军人事务部100亿美元合约打破。Epic当然参与了两项竞标，正如凯撒案例的翻版，最终角逐者仍是Epic与塞纳。

It remains the biggest until two years later when the VA contract does go out. That is a $10,000,000,000 deal. Now Epic, of course, bids on both of these contracts. And as you would expect, just like with Kaiser, it comes down to Epic and Cerner.

但并非直接参与，因为这个系统的荒谬之处在于，除非你经常竞标政府合同，否则基本上不可能直接竞标政府合同。所以你需要与那些专门通过与美国政府签订合同谋生的公司合作，成为他们分包链中的一环。

But not directly, because just to add to the insanity of the system, it's basically impossible unless you bid on government contracts all the time to bid on a government contract directly. So you need to pony up with one of the companies that subcontract off of someone who makes their bread and butter all the time by contracting with the US government.

没错。每家都会选择自己的合作伙伴，这其中充满了各种戏剧性。基本上各方都会亮出刀子。就像我们将在Cerner案例中看到的，如果你赢得其中一份或两份合同，我的意思是，这足以让你的公司维持运营很多很多年。抛开戏剧性不谈，最终Cerner赢得了国防部和退伍军人事务部的这两份合同。

Yes. So they each choose their partners, and there's all sorts of drama around this. Basically, the knives come out on all sides. As we shall see with Cerner, if you win one or both of these contracts, I mean, this will keep your company going for years and years and years. So drama aside, Cerner ends up winning both of these contracts, the DOD and the VA.

可悲的是，这或许完全不会让你感到惊讶——尽管这两个项目在投标阶段规模庞大，但都严重超时超支。情况非常非常糟糕。国防部的现役军人系统直到去年2024年底才完全上线。这份合同是2015年招标的，这意味着整个实施过程长达九年。

And sadly, in what will perhaps not shock you at all, both of these projects, despite being huge at the bidding phase, go massively over time and budget. It's really, really bad. So the DOD system, the active duty system, only just fully went live late last year in 2024. This contract got bid out in 2015. So that's a nine year implementation process.

退伍军人事务部的系统更糟。至今远未实现全面上线。

The VA system is way worse. It is nowhere near fully live today.

这两个都是Cerner赢得的？

And Cerner won both of these?

Cerner作为分包商赢得了这两份合同。退伍军人事务部系统是2017年招标的。关于该项目的最新公告是，按原话说，最早到2031年才能在全部退伍军人事务部站点上线。什么？即使按照他们宣称的最乐观情况——虽然看起来极不可能——这也是个耗时十四年的项目。

Cerner won both of these as a subcontractor, won both of these. The VA system was bid out in 2017. The latest announcement from the VA about this project is that it will be live at all VA sites by this is direct quote, as early as 2031. What? So even the most optimistic scenario that they're saying, which seems very unlikely, is this is a fourteen year project.

我最近看到的消息是它仍未上线。他们居然给出了最早2031年的时间表。

The latest I had seen is that it's still not live. They actually gave an as early as 2031.

目前已在少数站点上线。过去十年并非毫无进展，但是天啊。我是说，如果你是美国公民或关注美国的人，曾经对'有意义使用'计划感到恶心的话。如果你是美国纳税人，这简直令人作呕。

Now it is live at a few sites. It's not like nothing has happened over the last decade, but oh my god. I mean, if as an American citizen or watcher of America, you were disgusted by the whole meaningful use thing. If you are an American taxpayer, this is just beyond disgusting.

那么原因是什么？为什么耗时这么久，或者说为什么成本如此高昂？

So why? What took so long, or what made it so expensive?

我不太确定。我认为这是多种因素共同作用的结果。

I don't really know. I think it's a combination of a lot of things.

或者说，激励机制是什么？

Or I guess what are the incentives?

唉，虽然很不幸，但有句老话说，失败的政府合同比成功的更赚钱。我认为这可能就是当前起作用的激励机制。

Well, it's really unfortunate, but there's an old saying that you make more money on failed government contracts than successful ones. And I think that's probably the incentives that are applying here.

哦，因为只要合同不终止，你们还在实施阶段，就能不断发现更多成本。

Oh, because as long as the contract doesn't end and you're still implementing, you can still keep finding more costs.

你们就能持续获得报酬。不过我觉得全怪Cerner有失公允。他们虽是分包商，但总承包商是那些政府大承包商。就像我们在洛克希德那期节目里聊的，这就是当今军工复合体的运作方式。

You can still keep getting paid. Now I think it would be unfair to blame Cerner for this. I mean, maybe some of the blame lives on them, but they are a subcontractor to big government primes that are the GC here. I mean, we talked about this on the Lockheed episode. This is just how the military industrial complex works now.

所以这里叠加了政府官僚体系、军队、电子病历系统的层层桎梏——就像我们讨论过的，简直就是官僚主义的噩梦巢穴。这些耗资数百亿纳税人资金的跨十年项目至今仍未落地，简直荒谬至极。

So you got the compounding layers of bureaucracy of the government, the military, EMRs, generally, as we've talked about. Like, this is just like a rat's nest of awfulness of bureaucracy. And, you know, you've got these multi decade now projects with many billions of dollars of taxpayer dollars going into this. Still not live. Just freaking brutal.

你觉得Epic会不会庆幸自己没中标？

Do you think Epic is glad they didn't win?

事情是这样的：Epic当然参与了竞标，他们肯定很想赢得合同...

Well, so here's the thing. Epic, of course, was part of this process, bid on the RFPs, and I'm sure would have loved to have won them.

毕竟光是超支前的100亿初始报价，就是Epic目前年收入的两倍。顺利的话足以改变企业命运。

Because even the $10,000,000,000 initial price tag before the overruns is twice Epic's revenue today. It's transformative for your business in the best case.

没错，就像当年凯撒医疗彻底改变了Epic。根据对Epic客户、CIO和研究人员的访谈，他们现在简直跪谢Epic没拿下这个项目。

Yes. Kinda like Kaiser was transformative for Epic back in the day. Yeah. That's it. Talking to Epic customers and CIOs and the research, they are, like, down on their hands and knees thankful that Epic did not win this deal.

因为Cerner被这个流程拖垮了。

Because Cerner just got dragged so into the process.

就这样陷入了泥潭。当时还有许多其他复杂因素交织在一起。比如我们讨论过的Cerner，在被西门子收购后，你说过它已经整合了36家被收购的公司。创始人兼首席信息官、长期领导者尼尔·帕特森大约在这时患上了癌症，并于2017年去世。

So into the muck here. And there were a lot of other compounding factors happening here. Like, Cerner, like we've talked about, already was now post Siemens, what'd you say, 36 companies that had been acquired to Yeah. Get pulled together to make Cerner. Neil Patterson, the founder and CIO and longtime leader, right around this time he gets cancer, and then he passes away in 2017.

在这个极其复杂的进程中，你们的创始人和领导者去世了。之后几年里，Cerner频繁更换了多位领导者。与此同时，Epic没有国防部和退伍军人事务部那些破事的拖累（恕我直言），他们在大型医疗系统供应商中接连赢得一个又一个合同。

So your founder and your leader is passing away in the midst of this very complex process. After that, Cerner cycles through a whole bunch of different leaders over the next few years. And meanwhile, Epic, kinda unburdened by this DOD and VA shit show, for lack of a better word. And they just keep winning deal after deal in the large system providers.

而且是以他们自己的方式。这证明了朱迪认为公司应该如何运营：我们要保持极度专注，有非常明确的策略，会倾听客户需求。

And in their own way. I mean, this is a testament to how Judy thinks a company should be run. We're gonna stay extremely focused. We have a very particular playbook. We listen to customers.

我们兑现承诺，对软件工程和产品架构有着极致追求。当我们的

We meet our promises. We're hardcore about our software engineering and our product architecture. When our

客户发现新用例时，我们也会开发相应软件。她用非传统方式经营公司，而这种非常规方式被证明是赢得这个市场的正确之道。

customers find new use cases, we develop that software too. She runs a company in an unconventional way, and that unconventional way is proving to be the right way to win this market.

没错。在国防部合同之后，Epic赢得了波士顿Partners Healthcare的订单——这是哈佛与麻省总医院(MGH)组成的新实体，堪称顶级研究机构的代表。他们还拿下了梅奥诊所全部医院的合同，这是最大规模的合同之一，同样与国防部的混乱无关。

Yep. So after the DOD deal, Epic wins Partners Healthcare in Boston, which is the sort of new entity of Harvard and Mass General, MGH, and, like, the original big research institution. They win all of the Mayo Clinic, all of their hospitals. That's one of the biggest contracts. Again, outside the DOD craziness.

他们在英国赢得了剑桥项目，拿下了Intermountain Health，最近又获得Common Spirit Health的合同。这样的胜利接连不断。2018年，Epic收入达到27亿美元。

They win Cambridge in The UK. They win Intermountain Health. Recently, they win Common Spirit Health. The list goes on and on and on. 2018, Epic hits 2,700,000,000.0 in revenue.

他们宣布已签约《美国新闻与世界报道》排名中全部20家顶级教学医院，这至关重要——因为赢得顶级教学医院意味着所有在这些机构受训的新医生护士都将使用Epic系统。

They announced that they have all 20 of the top academic hospitals in The US News and World Report rankings, which is critical for them because winning the top academic hospitals means that all the new doctors and nurses that are coming through, getting minted by these institutions and trained are all trained on Epic.

我想他们还销售单独的教育许可证。他们把大学医院和学术课堂视为不同实体。当然在医院使用会有帮助，但学校也需要单独购买。

I think they sell them a separate educational license too. I think they treat the university hospital and the academic classroom as separate. I mean, I'm sure it helps to be in the hospital, but I think you also buy it as a school.

这点我同意，但医学教育的核心部分就是在医院实践。

I'm sure that's right, but also a huge part of medical education is practicing in the hospital.

我认为现在90%的医学院学生都在使用Epic系统进行培训。

And I think now ninety percent of med school students train on Epic.

是的。这是最新统计数据。2019年，Epic营收达到32亿美元。而到了2021年12月，正如我们一直暗示的，甲骨文以280亿美元收购了Cerner。正如我们讨论过的，Cerner曾经且现在仍是一家大公司。

Yes. That is the current statistic. 2019, Epic hits 3,200,000,000.0 in revenue. And then finally, December 2021, as we've been alluding to, Cerner gets bought by Oracle for $28,000,000,000. So Cerner, as we talked about, was and still is a big company.

这些年来他们收购了众多公司。营收可观，业务遍布全球，还持续持有国防部和退伍军人事务部的合同，这些带来了巨额收入。他们年营收大约55亿美元，或许更多些。但自2018年起就停滞甚至下滑。甲骨文于2021年完成了收购。

I mean, they've acquired all these companies over the years. There's a lot of revenue there, and they're big international, and they have the DOD and VA contracts ongoing, which was a lot of money coming in. So they're doing maybe, call it, 5 and a half billion a year in revenue, maybe a little more. But that's been flat to declining since 2018. Oracle, again, acquired them in 2021.

甲骨文现在不再单独披露Cerner的财务状况。他们将Cerner和Oracle Health称为（引用原话）拖累公司整体增长和盈利的'逆风'。Oracle Health已进行多轮裁员。或许现在下结论为时过早，但这很可能是甲骨文史上最糟糕的收购。很难找到分析师会认为这是甲骨文的明智之举。

Oracle now no longer reports Cerner's financials as a separate segment within the company. And they talk about Cerner and Oracle Health being a, quote, unquote, headwind to overall growth and profitability for the company. There've been a lot of layoffs within Oracle Health. You know, maybe it's too early to tell, but I think this is probably one of Oracle's worst acquisitions of all time. You'd be hard pressed to find an analyst who would say that this was a great acquisition by Oracle, shall we say.

没错。说得委婉些确实如此。

Yes. To put it lightly.

与此同时，这一切对Epic极为有利，完全印证了Judy在该领域构建公司的核心理念，以及她向客户传达的故事：一个专注于软件开发、百分百以客户为中心、永不收购其他公司、永不上市、永不被收购的单一集成平台。你就能理解为何客户会对他们如此拥戴。

Meanwhile, this is all just great for Epic and totally reinforces Judy's whole thesis of company building in this space and her whole story to customers of one single integrated platform that is hardcore about software development, that is 100% customer focused, that will never acquire another company, never go public, never get acquired. You can see why it's just this warm hug embrace to their customers out there.

是的。随着时间的推移，他们与市场上其他公司的差异越发明显。这其中有趣的启示是：他们起步很慢，非常缓慢地以某种方式积累势能，这些投入在二三十年后才显现回报，而非通过急功近利的方式透支未来。前二十年看起来像家平庸的公司，因为他们一直在积蓄力量，以成长为今日这般无懈可击的状态。

Yep. It becomes more and more different than everyone else in the market the longer time goes on. And the lesson here, which is really interesting, is they started slow. They started really slow, and they did things in a way where they almost built up momentum for the future in a way that would pay off twenty, thirty years down the road rather than inorganically trying to take shortcuts and pull the future too far forward into today. The first twenty years kinda looks like an unimpressive company because they were sort of just building strength, building muscle, growing the way that you need to grow in order to be as bulletproof as they are today.

这个观点非常精辟。早前讲述'有意义使用'政策时我就在思考：一方面它显然利好Epic并加速其发展，巩固了他们作为行业领跑者的市场地位；但另一方面，Epic内部员工对这个政策的态度却十分矛盾。

That's such a good point. And I was trying to square in my mind earlier when we were telling the Meaningful Use story, how on the one hand, it really was obviously good for Epic and an accelerant, and it further cemented the market dynamics where they were already emerging as the leader. On the other hand, when you talk to people within Epic, they're very mixed on meaningful use.

是啊。我始终无法确定他们说的'对我们帮助不大'是否只是客套话。因为从客户数量和营收曲线来看，当时发展势头非常好。

Yeah. And I could never figure out if that was, like, lip service of, oh, it didn't help us that much. But when you look at the graphs of customer counts and of revenue, it was going great.

确实。政策确实提前释放了部分增长，但即便没有它，趋势线最终也会到达这个位置。

Yes. It did pull forward some growth, but the trend lines were gonna get here anyway.

这并不像是一个在两年内发生的巨大阶跃函数。图表看起来并非如此。

It's not like it was some big massive step function in two years. That is not how the graphs look.

正如我们所说，他们拥有更好的产品。他们提供了更优质的客户服务。他们本就走在胜利的道路上。我想你提到的这一点很关键——他们从哲学上就始终对人为增长过敏。我在想这是否部分解释了为何他们对‘有意义使用’持真正矛盾态度时显得如此认真。

As we told the story, they had the better product. They had the better customer offering. They were on the way to winning anyway. I think to your point here about they've always been just philosophically allergic to artificial growth. I wonder if that's part of why to the extent they are serious about really being ambivalent about meaningful use, that's the reason why.

没错。他们想慢慢赢。他们绝对想赢。而且他们会赢，但他们想慢慢来，因为从长远看，缓慢取胜能让他们赢得更彻底。是的。

Yeah. They wanna win slowly. They absolutely wanna win. And they're gonna win, but they wanna do it slowly because it will help them win harder in the long run if they win slowly. Yes.

是的。

Yes.

所以对他们而言，我认为情况基本上从未如此光明。虽然有些风险我们会讨论，但他们现在开始在国际市场销售并真正开拓这个市场。规模还不大，但可以说占目前业务的10%到15%。2023年，他们在伦敦盖伊和圣托马斯NHS信托上线，这可能是他们有史以来最大规模的单次实施，而且发生在英国。

So meanwhile, for them, I mean, I think things have never looked brighter, basically. I mean, there's some risks that we'll talk about, but they're now starting to sell international and build that as a real market. It's not huge, but it's, you know, call it 10 to 15% of the business now. 2023, they went live at London's Guys and St. Thomas' NHS Trust, which was, I think, their biggest ever single implementation and happening in The UK.

英国正成为他们的重要市场。

The UK is becoming a real market for them.

有意思。要知道他们还有另一股强劲的顺风。就像你可能在整个节目中都听我说的，有些顺风不会让你感觉良好，但对Epic的业务仍是助力——医院系统正在加速合并整合小型地方诊所的趋势。哦，完全同意。

Interesting. You know, there's another big tailwind that's happening for them. And like you've probably been hearing from me over the course of this whole episode, there are tailwinds that don't make you feel good, but there's still tailwinds for Epic's business. The acceleration of the trend where hospital systems are merging and rolling up all the smaller local practices. Oh, totally.

这不过是个重新招标的借口。没错。这种现象有多重原因，其中之一是《平价医疗法案》。该法案还增加了行医的合规负担——多年来各种法规（包括高科技法案对违反HIPAA的重罚）已使负担很重。这是我们在高科技法案中没讨论的另一件事。

It's just an excuse to rebid. Yes. There's a bunch of reasons this is happening, but one of them is the Affordable Care Act. That also increased the compliance burden of practicing medicine, which was already really heavy from all the regulations over the years, including high-tech adding big penalties for HIPAA for violating HIPAA. That's another thing we didn't talk about in high-tech.

附加条款之一就是对HIPAA更严格的监管。因此现在作为地方执业医生，你需要规模效应才能承担合规成本。推演下去就意味着大多数医疗服务将由这些巨型医院系统提供，而非社区诊所——这极大有利于Epic，因为他们三十年前主攻最大最复杂医疗系统的策略如今看来堪称天才，因为现在剩下的主要就是这类客户。是的，完全正确。

That was one of the things that sort of came stapled onto it, was even more strict oversight on HIPAA. So you now require scale as a local medical practitioner to be able to afford the compliance burden. And what that means if you play it out is all health care or most health care gets provided by these mega giant hospital systems rather than community clinics, which really benefits Epic because their strategy from thirty years ago of going over the biggest and most complex health systems now looks totally genius because those are the only customers really left standing. Yep. Totally.

实际上我认为这是美国医疗体系中最混乱的现象之一。除了那些难以谈判、已获得生态系统大量话语权的私营健康保险公司外，你现在还面对地方性的准垄断大型医院系统。这种整合并不健康，也不会导致价格下降。就这么说吧。

I actually think this is one of the most messed up things in The US health care system. Aside from the really big hard to negotiate with private health insurers who have gotten a lot of power over the ecosystem, you now have also really big local pseudo monopoly hospital systems. And so this consolidation's not good. This consolidation will not lead to prices coming down. Let's just put it that way.

没错。但你也明白为什么会这样。你我刚开始做这期节目时，还以为医院才是反派，它们收费太高了。

Yep. But you see why it's been happening. You and I entered doing this episode expecting to be like, ah, the hospitals are really the bad guys. They're charging so much money.

而且我不认为医院很赚钱。

And I don't think the hospitals make very money.

它们根本不怎么赚钱，勉强维持生存，所以才要合并。

They don't make much money at all. They're barely surviving, which is why they're merging.

对。那些经营得好的医院赚的钱，也都会重新投入发展。就像我们讨论的，当今医院需要规模效应。所以它们建新大楼、收购当地诊所。所有人都在追逐规模，因为必须和其他大型机构打交道，自身也得壮大才行。

Right. And any money that the very successful ones are making, they tend to plow back into growth because, like we've been talking about, hospitals kinda need scale in this day and age. And so it's new buildings. It's acquiring other practices locally. Everyone is just chasing scale because they constantly are having to do business with other scale players, so they need to size up to do that.

是的。

Yep.

这就引出了Epic未来另一个重要增长方向——它们已在医疗服务提供方积累了足够规模，现在可以转向系统内其他大玩家：支付方、生物科技和制药公司，告诉他们'我们现在有合作方式，能提供吸引你们的产品'。Epic称之为'互联系统'或'照护网格'。其实就是为保险公司、药企、家庭护理公司等开发产品，但真正的大机会在支付方和制药领域。比如事前授权就是个例子。

So that brings us to the other big, I think, potential growth vector for Epic going forward that they're absolutely pursuing is they have enough scale on the provider side now that they can start going to the other big players in the system, the payers, and then also the biotech and pharma side, and say, we actually have ways that we can work with you guys now and offer compelling products to you. So they call this the system of connectedness or the, quote, unquote, grid of care that you might sometimes hear from Epic. But this is building products for and working with payers, the insurers, and pharma companies, and other stuff like home health companies or post acute rehab, etcetera. But, really, the big opportunities are payers and pharma. One example of this is prior authorizations.

没错。事前授权是美国医疗体系的大问题。当患者需要或医生认为患者需要某种药物或治疗时，保险公司会说'不能直接进行，必须先向我们申请个案承保'。

Yep. Prior authorizations are a huge problem in the American health care system. This is when a patient needs or a doctor thinks that a patient needs either a medicine or a procedure that the payer, the insurance company says, well, you can't just go do that.

这东西太贵了，你得先问我们是否给这个人报销。

It's expensive enough that you need to ask us first on a case by case basis if we'll cover it for this person.

对，正是如此。Epic现在拥有足够数据和医院端规模，可以对支付方说'事前授权，我们的客户不喜欢，你们也不喜欢'。

Yeah. Exactly. And we need you to prior authorize this. Epic now has enough data and enough scale on the hospital side that they can go to the payers and say, hey, prior auth, our customers don't like it. You don't like it.

我们掌握所有数据，可以直接帮你们自动化这个流程。

We have all the data. We can just automate this for you.

我认为这正是Epic最青睐的商业策略之一——我们先向医院系统销售核心产品，观察他们使用的其他供应商，然后判断是否也应从我们这里采购那些服务，前提是我们具备除单一供应商身份外的竞争优势。有时仅凭统一供应商的身份就足够有说服力，但他们还会评估是否能将其他服务纳入企业协议。他们希望向医院兜售一切，成为唯一的IT供应商。

I would argue this is an area where you are seeing one of Epic's favorite business strategies, which is we sell the main thing to a hospital system. We see what other vendors they're using. We figure out if they should also buy that from us, if we have some competitive advantage other than just single vendor to be able to do it. Sometimes just being a single vendor with the same offering is enough, but then they try to figure out if they can also do that and include it in their enterprise agreement. They wanna sell everything to the hospital and be the single IT vendor.

要知道，医院确实仍在采购其他IT服务。因此Epic的策略是从销售单一产品开始，逐步谋划如何向医院提供全套解决方案。当这个市场趋于饱和时，他们就开始探索新客户群体。这就是为什么他们将目光投向支付方和制药公司——如何利用现有资源，在基本占领当前市场后向其他客户扩展业务。

You know, the hospitals do still buy other IT services. So the epic playbook is go from selling a hospital one thing to figure out how to then sell the hospital everything. And then once you've sort of exhausted that, then figure out who else you can sell stuff to. And that's why they're looking into payers, and that's why they're looking into pharma companies. It's how can we leverage the asset that we have to then now that we've sort of saturated this market, sell to other customers too.

有道理。

Fair point.

好的，这就把我们带到了当下。如果你身处这个生态系统，可能会说Epic有50项业务我们都没提及。确实如此，我们不可能在本期节目中面面俱到。

Alright. So that basically brings us to today. If you're in this ecosystem, you're gonna say, there's 50 things that Epic does that you didn't talk about. That is true. There's no chance that we could talk about all of that on this episode.

但他们当前正在推进的一个非常酷的项目值得探讨，等我们梳理完现状后会重点介绍。接着我们将展示最新业务数据，讨论未来发展，最后进行分析。几年前他们推出了名为Kosmos的项目——没错，这确实很酷。

But there is one really cool interesting thing that they are doing right now that we do wanna talk about as we catch up to today. And then we'll give you the stats on the business today, and we'll talk about the future, and then we'll do our analysis. They launched something a few years ago called Kosmos. Yeah. This is pretty cool.

这太棒了。他们意识到：患者数据由患者和医院持有而非我们掌控，这些数据分散在不同服务器——有些在医院本地，有些在我们的云端，还有些在AWS上。

This is awesome. So they've realized, okay, there is data on patients that is owned by patients and hospitals, not by us, that lives on a bunch of different servers. Some are on prem at hospitals. Some are in our cloud. Some are on AWS.

还有些在Azure上。关键在于，Epic Care系统中存储着大量有价值的结构化患者数据。能否将其匿名化后整合到Epic托管的、支持高效查询的平台上供多种用途使用？他们做到了，这个名为Cosmos的系统现已包含2.95亿患者的匿名化数据。

Some are on Azure. But either way, there's all this interesting structured patient data stored in Epic Care instances. Can we anonymize that and get it all in an epic hosted instance of something very queryable and very useful for a bunch of activities? They did it. It's called Cosmos, and Cosmos has 295,000,000 patients worth of data in it, all anonymized.

是的，而且这2.95亿患者背后是150亿次诊疗记录。没错，就是医生与患者之间150亿次接触产生的结构化数据。

Yep. And I think that across those 295,000,000 patients, there's data from 15,000,000,000 individual patient encounters. Yes. So, like, structured data from a doctor encounter 15,000,000,000 times with patients.

这太疯狂了。我们之前提出的问题是：电子病历真的惠及患者吗？除了能在家查看记录这种便利，确实有大量数据表明它提升了患者安全性和就医体验。

It's crazy. So we were asking the question earlier, Do EMRs or EHRs really benefit patients? And there's some arguments that aside from how awesome it is to just access your records at home, there's a bunch of stats around, yes, it benefits patients. It's patient safety. It's patient ease.

研究显示45%的患者认为电子病历提升了医疗质量，仅6%感觉质量下降。Epic有组数据：2023年其系统预防了6600万次潜在药物不良反应和25万例潜在手术错误。如果你数字化追踪所有这些信息，就能通过智能手段提升医疗质量——这些数据看起来都非常可信。

There's studies that say forty five percent of patients reported improved quality of care with EHRs while only six noticed a decline. Epic has a stat. In 2023, its system prevented sixty six million potential adverse drug interactions and two hundred and fifty thousand potential surgical errors. All of this seems very plausible. If you're tracking all this stuff digitally, you can do intelligent things that improve care.

但更有趣的是，如果所有数据实际上都集中在一个地方，你可以对其进行操作，那会怎样？数字化相比纸质化有何价值？

But on top of that, more interestingly, what if all of the data was actually in one place and you could do stuff with it? What is the value of having something digital versus paper?

这有点像人们一直怀有的乌托邦梦想，也是布什政府和奥巴马政府曾追求的。EPIC终于实现了这一点。

This is sort of like the utopian dream that people have always had and that the Bush administration and the Obama administration had. EPIC is finally doing it.

是的。一个非常清晰有趣的例子是，想象一下供水系统出了问题，但所有记录都是纸质的。除非你去调取个别文件，然后查看一大堆人的特定测试结果——这可能需要研究资助才能坐下来调取所有这些单独文件——否则你不会发现问题。但如果你有一个完整的信息数据库，可以快速轻松地横向查看大量记录，这就是密歇根州弗林特市的情况。他们就是这样发现弗林特市的水质问题的，而在纸质记录的世界里，你永远无法发现这一点。

Yes. And one very clear interesting illustrative example is imagine there's something wrong in the water supply, but all the records are on paper. So unless you're going and pulling individual files and then looking at some specific test result across a whole bunch of people, which you probably need a research grant to do to actually go and sit down and pull all these individual files, you're not gonna find it. But if you have a whole database full of information and you can quickly and easily look horizontally across a whole bunch of records, this is Flint, Michigan. This is how they figured out there was a water problem in Flint, Michigan, and you would not have found it in a paper based world.

Kosmos将这一点发挥到了极致。如果你在一个匿名可访问的数据库中拥有2.95亿患者的数据，你能对整个世界了解多少？而且，任何贡献数据的机构都可以免费访问它。因此，在所有Epic客户中，任何选择加入的人都可以访问并查询它进行研究或酷炫的事情。比如，我有一个非常独特的患者，患有一种我从未听说过的疯狂病症。

Kosmos is that on steroids. What can you figure out about the whole world if you have 295,000,000 patients worth of data in an anonymized accessible database? And it's accessible to any institution for free that contributes data in. So of all the Epic customers, anyone who opts in gets to access and query it for research or cool stuff. Like, I have a really unique patient who has some crazy condition I've never heard of.

世界上还有其他人发生过这种情况吗？结果如何？

Has this ever happened to anyone else in the world, and what was the result?

没错。这正是最酷的地方。他们已经将其产品化，并免费提供给所有客户使用。所以，本，就像你说的那样。我是一名医生。

Yep. This is what's really cool. They've productized this and made it free that any of their customers can just turn it on. So, Ben, exactly like you're talking about. I'm a doctor.

我有一个患者，出现了一些问题。Kosmos可以向我展示，嘿，这里有一些类似案例的匿名例子。

I have a patient. There's something going on. Kosmos can surface to me, hey. Here are other examples of similar cases anonymized.

我想他们称之为‘相似病例’。

They call them lookalikes, I think.

是的。历史上所有使用过Epic的患者的相似病例。这里是治疗过那些患者的医生。所以我认为这在罕见病和奇特病例中已经相当常见了。

Yeah. Lookalike patients throughout the history of everybody that's ever been on Epic. And here are the doctors who treated those patients. So this is already happening quite a bit, I think, with rare diseases and crazy cases.

我也这么认为。它对临床试验有用，对研究也有用。我觉得目前它是免费的，这很有趣。我们得看看未来几年他们如何定价和包装它。

I think so too. It'll be useful for clinical trials. It'll be useful for research. I do think it's free right now, which is pretty interesting. We'll have to see how they price and package it in the coming years.