Anyone who has ever tried selling AI into health systems will tell you that it’s tough to compete with EHRs, but a new article in JAMA makes the case that it’s actually gotten too tough – and it might be time for regulators to step in.
Most markets reward the best products. The healthcare industry has a funny way of preventing that from happening, and EHR vendor dominance is a textbook example.
- EHRs hold advantages across infrastructure, workflow integration, procurement, and pricing that make it difficult for third-party tools to gain a foothold.
- A 2025 Health Affairs study backed that up by showing that 79% of U.S. hospitals use AI models from their EHR vendor, compared to just 59% that use AI from third-party developers.
- A Bain report drove the point home. Two-thirds of Epic customers said they’d pick a “good enough” Epic option over a better competing product.
These EHR advantages are a natural feature of the market. That said, it’s up to regulators to decide whether the status quo is serving patients and the overall healthcare system. The JAMA authors argue that it doesn’t, and offer three areas where targeted policy could level the playing field.
Infrastructure – Integrating AI tools into clinical workflows requires real-time data access and the ability to survive EHR upgrades intact, both of which are dramatically easier for EHR vendors – particularly as data fields get added or removed.
- Potential Policy – Mandate broader API adoption so third parties can access EHR data on equal footing, and use existing EHR certification and interoperability frameworks to do it.
Workflow and Usability – The authors specifically flag EHR vendors’ edge in understanding the trade-offs of allocating limited screen real estate to new AI tools, something that’s harder for third parties to gauge from the outside looking in.
- Potential Policy – Require EHR vendors to offer more robust developer sandboxes – similar to Apple’s iOS developer environment – so third parties can build and test without operating at a structural disadvantage.
Procurement and Pricing – Long-standing health system relationships give EHR vendors a streamlined path through procurement, as well as the leverage to “use pricing structures that incentivize adoption.”
- Potential Policy – Although this is the hardest area for a policy fix, the authors suggest that improving transparency around AI performance could at least help health systems make more informed decisions regardless of where a tool comes from.
The Takeaway
EHRs are in a powerful position, and companies in powerful positions have a long track record of making life harder for their competition. Healthcare is too important of an industry to not have the best products rise to the top, and this article offers some sound strategies to make sure that stays possible.
