This week I rode an escalator five stories into the Wisconsin earth.
At the bottom was an auditorium that seats more than ten thousand people, buried under a farm town outside Madison. It belongs to Epic Systems, the company whose software holds the medical records of most of the patients I will ever touch. Every August they throw a conference called UGM on their campus in Verona, and this year the whole thing was themed like a state fair. Midway signs. Blue ribbons. And an 82-year-old woman in Western garb walking out to address twenty thousand people who flew in to hear her.
Quick disclosure before we go further: I was there because my working life runs on Epic. Nobody paid me to write this, nobody asked me to write this, and Epic does not know I exist. I bought my own corn dog.
I went expecting a software conference. I left thinking about something else entirely, and it would not let go of me, so I am giving it three Saturdays. This week, the story of how the giant was built. Next week, the strangest succession plan I have ever seen. The week after, what the woman who built the electronic chart thinks about the machines that are coming for it.
Here is week one.
Three half-time people in a basement
In 1979, a math-degree mom named Judy Faulkner started a company in a basement in Madison, Wisconsin, with about $70,000 and three half-time people. Her father was a pharmacist. She had taken one course on computing in medicine and gotten hooked on a simple problem: keeping track of patient information.
That basement company now runs the medical records of more than 325 million patients. Roughly 42 percent of American acute care hospitals chart in Epic. The nearest competitor is barely half that. Revenue last year was around $5.7 billion. The campus I walked this week covers 1,670 acres and employs about 14,000 people, and it looks like what would happen if a children's book illustrator was handed a hospital IT budget. There is a treehouse conference room. There are themed buildings. There is that underground auditorium.
Standing on that campus, the obvious question is how. How does a basement operation in Wisconsin beat General Electric, Google, Microsoft, and everybody else who came for this market?
The answer I kept running into is not what she did.
It is what she refused to do.
The refusals
Epic has a set of internal principles they call the Ten Commandments, and they are posted in the bathrooms. The first two:
Do not go public.
Do not acquire or be acquired.
In forty-seven years, Epic has never taken a dollar of venture capital. Never bought another company. Never sold itself, despite decades of the biggest names in tech sniffing around. Never left Wisconsin. Judy's reasoning on acquisitions is almost boring in its practicality: when you bolt on someone else's product, the terminology differs, the coding differs, the screens differ, and it stops working smoothly for the people who use it. So they build everything themselves, slowly, on one system.
Think about what that meant in practice. Every year for forty-seven years, there was an easier option on the table. Take the money. Buy the competitor. Cash out at a valuation with eleven digits. Her longtime rival Cerner said yes to Oracle for $28 billion. Judy said no, again, to all of it, for half a century.
The moat was never the software. The moat was the accumulated weight of every no.
No to investors meant no one could force a pivot for a quarterly number. No to acquisitions meant one coherent product instead of a stitched-together Frankenstein. No to going public meant they could plan in decades while everyone else planned in quarters. Each refusal looked like leaving money on the table. Compounded over forty-seven years, the refusals were the strategy.
The fair case against her
Now let me argue the other side, because it is real.
The same discipline that built one coherent system also built a closed one, and plenty of smart people resent it. Epic is currently facing antitrust suits, including one from a company called Particle Health and one from the attorney general of Texas, alleging the company uses its market power to squeeze out competitors. Judy calls the monopoly claims weird for a company that started with three half-time people in a basement. The courts will decide whether dominance earned patiently is still dominance that harms.
And I will say this as a physician: the system her refusals built is also the system I click through a few thousand times a shift. The coherence is real. So is the burden. Both things came out of the same basement.
The bottom line
I do not think most of us should copy Judy Faulkner. For every company that refused everything and won, there are a hundred that refused everything and quietly died, and we never hear their story. Survivorship bias is doing some work here, and she would probably be the first to admit luck and timing did too.
But walking that absurd, wonderful campus this week, I kept thinking about my own ledger. Most of us do not have a strategy problem. We have a yes problem. We say yes to the extra commitment, the shiny opportunity, the thing that looks like money now, and each yes seems harmless until you realize twenty years passed and you built something incoherent.
She built a giant out of refusals. Most of us are building our lives out of accumulated yeses we never examined.
So here's my question for you this week: what is the no you already know you should be saying, and what has saying yes been costing you?
Reply and tell me.
That's all for this week.
See you next Saturday, when we get to the strangest part of this story: what happens to Epic after Judy. She has a plan, and part of the plan is a standing army of people whose only job is to sue.