In 2012 a drug company or cancer researcher who wanted to know how cancer patients were treated in ordinary practice, and how they fared, had little to go on. Clinical trials, the standard source of evidence, enrolled about four percent of US adults with cancer FH42 FH16. For everyone else, the details 'from the molecular characteristics of their tumors to the outcomes of their treatments' were 'locked away in unconnected electronic and paper records', as the oncologists' professional society put it that year FH48. Many cancer hospitals could not say in real time how many of their own patients had pancreatic cancer FH1, and much of what research needed, such as stage and response to treatment, sat in doctors' notes and scanned reports rather than in fields a computer could count FH38.
Flatiron Health
Flatiron Health bought a cancer-practice records system to reach enough patients for drug companies, then paid clinicians to turn those charts into research data that regulators came to use and nearly every cancer drugmaker bought.
How Flatiron Health won
- 1 · 2013–18Own the oncology record, not a layer over itGenentech said too few patients; about $100M of a $130M round bought OncoEMR and its 550,000 patients a year.M&A Strategy
- 2 · 2014–18Paid clinicians to read the chartsAbout 1,000 trained abstractors turned doctors' notes into research variables that structured fields missed.Tech-Enabled Services
- 3 · 2016–19Regulator-grade evidence, built with the FDAAn FDA research collaboration in 2016, trial control arms reproduced, then Flatiron data in the 2019 Ibrance label.Trust
- 4 · 2014–22Sell the same data to every drugmakerNon-exclusive even to its investor Roche; 14 of the top 15 cancer drugmakers by 2018, all of the top 20 by 2022.Data Licensing
- 5 · 2018–25Catch-up barrier of curated records and regulatory standing3.4 million traceable curated records and a decade of human labels that now validate AI extraction.Accumulated assets & catch-up barriers
Versus ASCO CancerLinQ: CancerLinQ pooled feeds from record systems it did not own and could not afford to clean them. Flatiron owned the record, paid clinicians to curate it, and sold the result to every drugmaker, which paid for more curation.
Arena: Market Conditions Before Flatiron Health
How each step happened
Step 1 of 5 · 2013–18
Own the oncology record, not a layer over it
Flatiron began as a layer over other companies' software. The founders, Nat Turner and Zach Weinberg, had sold an ad-technology company to Google; they spent about two years interviewing clinicians and researchers, then built OncologyCloud, analytics that sat on top of the electronic health records (EHRs) cancer centers already ran FH1 FH51. About 20 centers signed up by 2014. When the founders pitched drug companies, though, Genentech called the technology 'awesome' but said it covered too few patients to be useful FH1. Selling dashboards had also taught Turner that the centers' EHRs were 'most of the problem': 'we needed to become the EHR or at least have an EHR option' FH5.
In May 2014 Flatiron put about $100 million of a $130 million round into buying Altos Solutions, whose OncoEMR record system served 1,300 clinicians treating 550,000 patients a year FH2 FH1. It was the only one of four specialty oncology EHRs not owned as a side business by Varian, Elekta or McKesson FH1. The purchase quintupled Flatiron's cancer-center partners FH5, and by 2018 OncoEMR was used by nearly 280 practices treating 2 million patients FH1. Owning the chart where community oncologists recorded care answered Genentech's objection. Practices ran their clinics on it every day, and the same record, de-identified, became the raw material for research datasets.
Rivals ASCO's CancerLinQ pulled data from practices' existing systems instead: its 2013 prototype drew on eight record systems and found more than 60 ways of recording one white-blood-cell count, and it launched in 2015 with 15 practices and about 500,000 patients FCL-2. McKesson held a comparable oncology record, iKnowMed, but packaged it as a data business only in 2020 FH23.
Step 2 of 5 · 2014–18
Paid clinicians to read the charts
The record gave Flatiron the patients, not the research data. Amy Abernethy, who had run Duke's real-world evidence program and joined as chief medical officer in 2014, estimated that '50% or more' of the critical data points lived in unstructured documents such as pathology reports FH5 FH38. Flatiron chose to pay people to read them. It built a workforce of clinically trained abstractors, often oncology nurses, working to standardized policies, and by 2018 it paid about 1,000 contractors to turn notes into data FH14 FH1.
The labor mattered because structured fields alone gave a different answer. A Pfizer and Flatiron analysis found that patient groups built from structured fields differed greatly from those that also used the notes FH38. Carolyn Starrett, CEO from 2021, said early machine learning and language processing were not enough for clinical quality FH19. What drugmakers bought was a finished dataset they could set beside trial data, and David Shaywitz, writing at the Roche sale, named 'meticulous, artisanal data curation, largely done by hand' as the difference FH38. From 2018 machine learning chose which charts to abstract, and an abstractor still confirmed each result FH34.
Rivals CancerLinQ aggregated practice feeds on an SAP HANA platform FCL-5. By late 2017 ASCO said storing and curating the data had outgrown its capital and expertise and handed the structuring to Tempus and Precision Health AI; only about 40 of some 100 sign-ups had been activated FCL-1.
Step 3 of 5 · 2016–19
Regulator-grade evidence, built with the FDA
Curated data was worth most if a regulator would accept it. In May 2016 Flatiron signed a research collaboration with the FDA's drug center on immunotherapy in advanced lung cancer and gave the agency access to its data FH42 FH38. By 2018 Flatiron's researchers had reproduced the control arms of existing trials more than a dozen times FH1. Shaywitz's reading was that if regulators accepted Flatiron's data, drug companies could trust it too FH38.
Buyers paid for that standing. When Roche bought Flatiron in 2018, its pharmaceuticals chief called 'regulatory-grade real-world evidence' a key ingredient of the deal FH4, and Bristol-Myers Squibb's three-year deal weeks later was built around curating regulatory-grade data FH31. In April 2019 the FDA extended Pfizer's breast-cancer drug Ibrance to men using Flatiron's breast-cancer database alongside IQVIA insurance claims and Pfizer's safety data FH12. By then Abernethy had become the FDA's principal deputy commissioner FH12, and the other data companies were defining shared endpoints with Flatiron in a Friends of Cancer Research pilot FH22.
Rivals CancerLinQ's FDA collaboration, on checkpoint inhibitors, began in August 2018, two years after Flatiron's, with the curation done by Tempus and Concerto HealthAI; its CEO said such work had to span the cancer community because no single organization could do it FCL-4. IQVIA's claims served beside Flatiron's charts in the Ibrance review, not in place of them FH12.
Step 4 of 5 · 2014–22
Sell the same data to every drugmaker
Selling began with Pfizer in 2014 and ran alongside the first three steps FH20; what they made possible was one dataset sold to every competing drugmaker. Roche's 2016 investment came with a purchase agreement written as non-exclusive FH6, and by the February 2018 sale Flatiron worked with 14 of the top 15 cancer drug companies FH25. Roche paid $1.9 billion for the 87.4% it did not already own and kept Flatiron a separate company with segregated patient data and its own sales team, promising to preserve its 'ability to continue providing their services to all existing and future partners' FH4 FH25. Abernethy pointed to firewalls 'between even our clients and our owner' FH31. By 2022 Flatiron said it worked with all of the top 20 FH19.
Neutrality was part of the product: a drug company buying evidence about a rival's drugs wants a supplier no rival controls. Oncologists used the software, and the data their use produced was curated once and licensed to many buyers FH38. Accounts also widened; Pfizer's collaboration was expanded in 2019 to development projects across several tumor types FH20. By 2024 data sales were about two-thirds of revenue, the Financial Times reported, though Roche's ownership had put some drugmakers off and Roche was weighing a sale FH10 FH9.
Rivals CancerLinQ licensed its database to Tempus and Precision Health AI for fixed annual payments in December 2017, and ASCO's CEO said it still cost tens of millions of dollars a year and would keep losing money FCL-3. After 2018, vendors without a drugmaker owner, such as IQVIA, Tempus and McKesson's Ontada, gave buyers a neutral alternative FH23 FH49.
Step 5 of 5 · 2018–25
Catch-up barrier of curated records and regulatory standing
The sales funded an asset a later rival cannot buy at today's prices. By 2024 Flatiron's data covered about 3.4 million patient records, with every abstracted data point traceable through an audit trail to its source document FH14. The FDA renewed its collaboration for five years in 2023 FH13. When language models made automated extraction practical, the decade of human-abstracted records became the benchmark: Flatiron could compare what a model extracted with what a trained abstractor had found FH32.
A rival starting later has to pay for the curation and for the years of methods work with regulators. ASCO judged that 'hundreds of millions of dollars' were needed to cleanse and structure CancerLinQ's nearly 7 million records, and sold it to ConcertAI in December 2023 FH43. The barrier goes back to step 2: the abstraction labor that made the data saleable is what now lets Flatiron automate with a regulator's confidence. It protects against later data builders, not against buyers' doubts about the owner: the drugmakers that stayed away in 2024 did so because of Roche FH9.
Rivals CancerLinQ held more records than Flatiron, nearly 7 million from 10 record-system integrations, but ASCO could not fund structuring them FH43. Tempus and ConcertAI kept competing for the same licensing budgets FH49.
Key dates
- 2012Founded after a two-year listening tour
- 2013-01OncologyCloud: analytics over cancer centers' existing systems
- 2014Abernethy joins as chief medical officer; Pfizer collaboration begins
- 2014-05Buys Altos and its OncoEMR record system
- 2014-05550,000 patients a year Treated by OncoEMR's 1,300 clinicians at purchase FH2
- 2016-01Roche leads a round with a non-exclusive purchase agreement
- 2016-05Research collaboration with the FDA
- 2017-12CancerLinQ licenses its data to Tempus and Precision Health AI FCL-3
- 20182 million patients On OncoEMR at nearly 280 practices FH1
- 2018Nearly $200M revenue Annual, Forbes estimate (2018) FH1
- 2018-02Roche buys the rest for $1.9 billion and keeps Flatiron separate
- 2018-0214 of the top 15 Cancer drug companies as customers FH25
- 2018-08CancerLinQ starts FDA research, curated by Tempus and Concerto HealthAI FCL-4
- 2019-04Ibrance extended to men with Flatiron data in the review
- 2022All of the top 20 Oncology drug developers as customers, per the CEO FH19
- 2023-09FDA collaboration renewed for five years
- 2023-12ASCO sells CancerLinQ to ConcertAI FH43
- 20243.4 million patient records Curated, each data point traceable to its source FH14
- 2024-08Roche weighs a sale; its ownership reported to deter drugmakers
- 2025-12Clinical research business sold to Paradigm; OncoEMR kept
Sources
Oldest first.
- FH48 ASCO's CancerLinQ: Building a Transformation in Cancer Care. Outside analysis
- FHX6 CancerLinQ and the Future of Cancer Care. Peer-reviewed article
- FH51 Flatiron Health Raises $8M From Google Ventures, First Round .... Contemporaneous trade or press report
- FH46 Flatiron Health Raises $8 Million .... Company release
- FH3 Cancer data analytics team Flatiron Health acquires specialized EMR business Altos, raises $130M. Contemporaneous trade or press report
- FH47 Google Ventures Leads $130M Series B In Cancer Data Startup Flatiron Health. Contemporaneous trade or press report
- FH2 Flatiron Health Raises $130 Million Series B ... Agrees to Acquire Altos Solutions. Company release
- FHX8 Altos Solutions Acquired by Big Data Leader Flatiron Health. Company release
- FH16 Flatiron Health's bold proposition to fight cancer with big data. Contemporaneous trade or press report
- FCL-5 ASCO Announces Partner for CancerLinQ Platform. Contemporaneous trade report
- FH17 90% of Feedback is Crap: How to Find the Next Big Startup Idea. Interview
- FH6 Flatiron Health Raises $175 Million Series C Round .... Company release
- FH45 GV's Approach To Healthcare Investing: An Interview With Dr. Krishna Yeshwant. Interview
- FH36 Oncology Consultants Selects Flatiron Health OncoEMR. Customer account
- FH5 Up and Comers 2016: Flatiron Health. Interview
- FCL-6 CancerLinQ Completes Agreements With 36 'Vanguard' Practices. Society trade publication
- FH42 Flatiron Health and the FDA Embark on Cancer Research Collaboration. Company release
- FH7 Update: Flatiron Health putting $175 million Roche investment to work. Contemporaneous trade or press report
- FH37 Flatiron Health Expands Technology Partnerships with OCM Practices. Customer account
- FCL-3 Deal struck to mine cancer patient database for new treatment insights. Contemporaneous trade report with executive quotes
- FCL-1 ASCO forms collaboration with two Big Data firms to grow CancerLinQ. Contemporaneous trade report with executive quotes
- FH41 Roche To Buy Big Data Upstart Flatiron Health For $1.9 Billion. Contemporaneous trade or press report
- FH25 Roche buys cancer data company Flatiron Health for $1.9B. Contemporaneous trade or press report
- FH39 Why Drug Giant Roche's $1.9 Billion Deal ... Matters. Contemporaneous trade or press report
- FH4 Roche to Acquire Flatiron Health .... Company release
- FH38 The Deeply Human Core of Roche's $2.1B Tech Acquisition. Outside analysis
- FHX9 The Deeply Human Core ... (Forbes original). Outside analysis
- FH8 Roche acquiring Flatiron Health is the biggest looming healthcare disruption.. Outside analysis
- FH15 Beyond Flatiron: The Rising Power of Oncology Clinical Data Companies. Outside analysis
- FH40 The 32-year-old who sold his first company for $80 million and a second for $2 billion .... Interview
- FHX1 After Roche's Acquisition Of Flatiron Health, Here's Who Else Could Be Shopping .... Outside analysis
- FH18 The 32-year-old CEO of a $2 billion startup says he and his cofounder are driven by paranoia. Interview
- FH24 Flatiron Health, Purchased By Roche, Signs Three-Year Deal With Bristol-Myers. Contemporaneous trade or press report
- FH31 Flatiron, BMS form collaboration to curate regulatory-grade real-world data. Contemporaneous trade or press report
- FCL-4 Tempus to Collaborate with CancerLinQ LLC and U.S. Food and Drug Administration on Checkpoint Inhibitors. Company press release
- FH34 The Role of Machine Learning & NLP in Real-World Evidence. Company release
- FH1 At 24, Two Entrepreneurs Took On Cancer. At 32, They're Worth Hundreds Of Millions. Contemporaneous trade or press report
- FH35 OncoEMR Top-Rated ... KLAS 2019. Company release
- FH12 How FDA, Pfizer, and Flatiron Health did it: Approval Of Ibrance For Men .... Contemporaneous trade or press report
- FH20 Pfizer and Flatiron Health Announce Expanded Strategic Collaboration .... Customer account
- FH22 Real-world evidence at a glance: How a collaboration of 'frenemies' .... Contemporaneous trade or press report
- FHX4 Zach Weinberg, Flatiron Health (Theory and Practice S1E10). Podcast
- FHX2 How Two Founders With No Health Care Experience Built a $2 Billion Oncology Startup. Outside analysis
- FH33 Risk Taking and Entrepreneurship: Interview with ... Nat Turner. Interview
- FH23 McKesson Launches Ontada .... Company release
- FHX7 McKesson Launches Ontada. Company release
- FH21 Flatiron Health Announces Carolyn Starrett as New CEO. Company release
- FH19 Flatiron CEO Carolyn Starrett: We're reimagining the infrastructure of cancer care .... Interview
- FH52 Flatiron Health Expands Beyond Real-World Data .... Company release
- FH44 Epic Leads Medical Oncology EHR Market in Customer Satisfaction. Outside analysis
- FH13 Flatiron Health enters new five-year research collaboration with FDA on real-world data. Company release
- FH43 After more than a decade, ASCO sells CancerLinQ to ConcertAI. Contemporaneous trade or press report
- FH14 Raising the Bar for Real-World Data in Oncology: Approaches to Quality Across Multiple Dimensions. Peer-reviewed article
- FCL-2 Building CancerLinQ for the Future: The Next Step for an Ambitious ASCO Project. Owner's retrospective (society magazine)
- FH49 Tempus AI S-1. Outside analysis
- FH26 Roche considering divesting $1.9 bln cancer data startup, FT reports. Contemporaneous trade or press report
- FHX12 FT. Contemporaneous trade or press report
- FH10 Does Roche have buyer's remorse for Flatiron takeover?. Contemporaneous trade or press report
- FH9 Roche considering sale of cancer data startup Flatiron Health: report. Contemporaneous trade or press report
- FH32 Flatiron Health sees shift from 'what if' to 'what is' in RWE. Interview
- FH30 Flatiron Health appoints Nathan Hubbard as Chief Executive Officer. Company release
- FH27 Paradigm Health acquires Flatiron Health's Clinical Research business .... Company release
- FH28 Paradigm Health, seeking to use AI to enroll clinical trials, partners with Roche. Contemporaneous trade or press report
- FH11 ARCH-backed Paradigm snaps up Flatiron's clinical research business. Contemporaneous trade or press report
- FH50 RWD analytics firm Verana Health buys COTA Healthcare for $52m. Contemporaneous trade or press report
- FH29 Flatiron Health Names New Chief Business, Technology, and Product Leaders. Company release
- FHX10 (unknown PMC article on CancerLinQ/rapid learning). Peer-reviewed article
- FHX11 Cornell Tech at Bloomberg Ep.35 - Zach Weinberg. Podcast
- FHX3 Interview with Zach Weinberg. Interview
- FHX5 Flatiron Health CEO and Co-Founder Nat Turner (Duos podcast). Podcast