HIStalk Readers Write

The Operational Divide in Healthcare: Epic-First Health Systems Versus Real-Time Health Systems

An ongoing split is forming across US healthcare, a divide that health system leaders are driving overtly or by default.

On one side are the organizations building real-time reflexes into their operations. On the other are the organizations whose pace is still dictated by vendor-defined data access paths, delayed data, and workflows that are constrained by the vendor architecture.

This divide isn’t philosophical. It is operational. And it is widening fast. This will be the competitive divide for the next decade.

Two Emerging Camps

Markets don’t stall because of a single vendor. They stall when incumbents limit the freedom for customers to move faster, choose better, and innovate on top of their own data. As modernization accelerates, health systems are sorting into two identifiable groups:

Real-Time Health Systems

These organizations are developing the ability to govern their own data access, sense operational signals as they occur, and route actions immediately. They are beginning to build reflex loops, which are lightweight, programmable logic that prevents revenue loss (fewer denials, reduced LOS), mitigates safety drift, reduces manual intervention, and stabilizes workflows before problems compound. They seek destiny control and predictable value creation.

These organizations lean toward independence in how they access and use their own data, and they treat delay as a form of waste rather than an unavoidable byproduct of enterprise IT.

Epic-First Health Systems

These organizations face the same challenges as real-time health systems, but move at the speed of vendor-mediated access. They depend on (costly) sanctioned interfaces, roadmap timelines, batch extracts, and manual processes to identify operational issues. Limited tooling to say the least.

These organizations treat delays as an avoidable byproduct of enterprise IT and accumulating operational drag is their norm.

Why the Divide Is Forming

Four forces are driving the move to real-time health systems faster than the industry expected:

• Labor costs in healthcare have risen faster than inflation for five decades, while inflation-adjusted revenue per encounter has steadily declined as commercial mix shrinks. There is no way out from under the current operating model, and no real way to differentiate in most markets if you keep playing the old game.
• Operational latency is a margin killer. Discharge delays, denials identified too late, referrals never acknowledged, eligibility errors discovered only after work is performed. Growth in small lags produces large financial consequences.
• Vendor-controlled access is mismatched to modern workflow demands. Today’s problems require continuous monitoring, immediate detection, and on-demand logic. Architecture designed for retrospective insight isn’t built for real-time operations. HL7/X12 alone doesn’t cut it, and FHIR resources and vendor-gated APIs are imprecise and overly narrow.
• AI and automation cannot run on delayed signals. The industry is extremely optimistic about automation, but models and agents (and the workflows health systems are pointing them toward) are useless without upstream real-time detection. If an organization only learns that a problem occurred after the fact, no amount of workflow redesign can compensate.

These forces have shifted the strategic question from “What technology do we need?” to “How fast can we recognize and act on our own operational signals?” as the foundation for automation and innovation capabilities.

The Hidden Cost of Delay (Waiting is a Cost Center)

• Throughput slowdowns that no one sees until the backlog materializes.
• Denials that could have been prevented if noticed earlier.
• Eligibility mismatches found only in downstream billing.
• Referral leakage due to missed handoffs.
• Safety triggers that surface only when reports are pulled.

Every service unit has its list, but they look remarkably similar across health systems.

While these issues rarely appear as technology failures, they often show up as operational realities. Every one of these problems is a real-time problem trapped in a legacy data access model. The cost of delay is not just inefficiency, but also lost margin, avoidable friction, patient harm, and workforce strain.

What Real-Time Reflexes Look Like

Organizations that operate in real time do not wait for dashboards to tell them what happened. They program their systems to notice and act on what matters in real-time:

• Detecting a mismatch the moment it occurs.
• Automatically triggering a task or action.
• Routing information directly to the workflow that requires it.
• Logging the event without human intervention.
• Measuring impact within hours, not quarters.

Acting and adapting fast, which few systems do well today, is a strategic market differentiator and quickly becoming a survival imperative as this divide widens. This is the identity high-performing systems realize they must rise to.

Claiming Control of Your Own Data

The executive unlock is straightforward.

• Your vendor has an obligation to allow access to your data however you choose.
• Your vendor has a legal duty not to interfere with your use of your data.
• Acting on your rights does not mean being in conflict with your vendor.
• Sovereignty is not about choosing one technology path over another. It is about ensuring that the parts of the health system that depend on real-time signals (care transitions, revenue cycle, safety, operations) are not forced into delay by design.

Crossing the Divide: A Simple Playbook

Health systems don’t need multi-year digital transformation programs to build real-time reflexes. They need clarity and sequence.

1. Map your highest-delay workflows. Where do teams wish they had real-time visibility but are stuck with overnight insight?
2. Evaluate control. What should be legitimately controlled by the vendor versus what should be governed by the health system. This is almost always the inflection point.
3. Test one workflow in real time. Pick one workflow and simply measure what happens when teams get the signal immediately instead of a day later. No committees or giant work plan, just a clean before and after.
4. Scale reflex logic across additional domains. Once a health system sees its first real-time win, the pattern becomes contagious.

A Narrow Window

Every health system will be forced to modernize its reflexes. The question is timing.

Organizations that move now will define the performance frontier and expand markets. Those that wait to modernize will fall further behind.