Epic controls 42% of the US EHR market. Does that help or hurt interoperability?

Epic's influence is a double-edged sword  

Founded in 1979, Epic began in a basement with three half-time employees, according to its website. Now, the company has over 14,000 employees. KLAS data also shows that Epic EHRs cover a little over half (55%) of the 887,124 acute care beds in the United States.

Its exponential growth has allowed the company to shape the industry's health IT standards. According to Zachary Tisch, partner of portfolio services at professional services firm Pivot Point Consulting, Epic has enforced consistency across the health IT landscape, especially in technical configurations.

Epic has been able to deliver a more seamless experience faster within its own ecosystem, and that naturally reinforces buyer preference for solutions that stay inside that ecosystem.

This consistency helps lower the barrier to entry for new digital health companies. If new digital health tools are compatible with the Epic EHR, they can be more easily implemented across the many organizations that use the platform. This compatibility is achieved through application programming interfaces, as well as the Fast Healthcare Interoperability Resources interoperability standard developed by Health Level Seven International and the SMART on FHIR technology framework, which uses FHIR to run applications within EHRs.

"One of the nice things about that standardization is if I've integrated with one Epic site and get those APIs or that SMART on FHIR HL7 interface set up, they're going to be 90% repeatable as I go to other organizations using Epic," he said. "We're typically not seeing a lot of custom code."

Brendan Keeler, interoperability practice lead at HTD Health, a strategy and technology consultancy, agreed, adding that the company has "released more FHIR APIs in the past two months than the rest of the industry combined."

According to Epic, the company has released more than 50 new APIs over the past six months to improve provider-payer communication and speed prior authorization approvals, and more than 1,000 APIs and interfaces are available to developers for free on open.epic.com. 

With these releases, Epic offers widespread connectivity to other health IT developers, which ultimately supports interoperability goals.

"Today, more than 2,500 third-party apps are live and exchanging data using our public APIs, with over 252 billion transactions per year," an Epic spokesperson said in the email.

Tisch further noted that the company has delivered interoperability support among its customers. For example, Care Everywhere, Epic's interoperability network that enables the secure transfer of medical records, was launched nearly 20 years ago in 2008. According to the company, 27 million charts are exchanged daily via Care Everywhere, of which half are sent to non-Epic platforms.

"Epic has been able to deliver a more seamless experience faster within its own ecosystem, and that naturally reinforces buyer preference for solutions that stay inside that ecosystem," he said.

But, according to Tisch, this has also had the side effect of creating groups of "haves" and "have-nots" within the U.S. healthcare industry: those within the Epic network and those outside it.

"We're very much seeing that there are two worlds in today's interoperability landscape," he said.

Dan D'Orazio, CEO of healthcare consultancy Sage Growth Partners, noted that, in some ways, Epic has made it hard for the ecosystem to achieve widespread interoperability.

With advances in healthcare technologies, both in and out of the hospital, physicians have access to more patient health data than ever before. But with one dominant company like Epic operating within a walled data garden of sorts, D'Orazio noted that companies developing these technologies could be left out if they cannot forge a partnership with Epic. Ultimately, Epic can choose which companies can access its troves of data and its health system clients.  

In addition, Epic's growing suite of capabilities could have a stifling effect on innovation. D'Orazio shared that conversations with clients often include strategies for if and/or when Epic launches a similar tool. When rolling out a new tool, Epic has the advantage of already being a part of a health system's IT ecosystem versus an emerging company that must forge those partnerships one by one. 

"It's very hard when companies are trying to innovate because Epic is a core system, and they want to do lots of other stuff," D'Orazio said. "Epic says, 'You don't need to buy anything else because you have us,' and they just build stuff that other people do, and then say, 'Just get it from us.'"

Tisch echoed D'Orazio, adding that health systems tend to operate with an "Epic-first" mindset. When Epic launches a capability, health systems gravitate toward it because it is already within their usual workflows, which makes the capability easier to purchase, implement, govern and scale.

"The flip side is that 'best' and 'easiest' are not always the same thing," he said. "A standalone third-party solution may offer deeper functionality or more innovation, but it also introduces more interoperability complexity, more vendor coordination and more cybersecurity considerations because data has to move across more systems and trust boundaries."

This friction in the health IT market, alongside Epic's position as a gatekeeper of data, has resulted in more than one high-profile lawsuit against the company.

Lawsuits attempt to curb Epic's influence

In September 2024, health IT vendor Particle Health filed a federal antitrust lawsuit against Epic, claiming the company used its power in the EHR market to bar Particle from the emerging payer platform market.

Particle Health's platform uses APIs to aggregate and normalize medical records across EHRs. In the lawsuit, the company claimed that Epic was hoarding data and using a "multi-tentacled approach to try to squash Particle." The suit further stated that Epic's curbing of EHR data access negatively impacts clinicians and patients.

"Epic has and can decide to shut off the sharing of information," Jason Prestinario, CEO of Particle Health, said in a recent interview with Health IT and EHR. "And so, if Epic controls that data and shuts it off, then every single one of those individuals across the country can have their care suffer. That level of control and influence is exactly the thing that we think is inappropriate and needs to be curtailed."

The lawsuit further claimed that Epic blocked data from Particle's customers, including a network of community oncology centers. As a result, Epic providers treating those patients did not have access to critical patient care information collected at the community centers.

Epic has and can decide to shut off the sharing of information...That level of control and influence is exactly the thing that we think is inappropriate and needs to be curtailed.

"If this data is anyone's, it's the patients," Prestinario said. "Not Epic's, not the health systems, not the payers, right? All those entities can and should have rightful access to it, but if it's anyone's data, it should be the patient's data and the ability for someone to step in and control where that data goes -- in many cases in direct violation of that patient's desire -- and setting up scenarios where that patient's care is impacted negatively is what we're trying to prevent."

However, Epic maintains that the patient and their providers have the final say over their data and who can access it.

"Health systems using Epic, and their patients, choose which apps to use. Our health system customers are the custodians of healthcare data on behalf of their patients. Patients and providers decide where to send the data, not Epic," the spokesperson said.

Soon after Particle Health filed the suit, Epic asked the federal court to dismiss it. The company levied its own allegations against Particle, stating that the lawsuit is "Particle's attempt to distract from the public reckoning stemming from Particle's customers violating patient privacy by improperly accessing patient records for non-treatment purposes, such as when Particle knowingly enabled access to patient data for a company that sells medical records analysis for class action lawsuits."

However, in September 2025, a federal judge allowed the suit to move forward. While the judge dismissed some of Particle's allegations, including that Epic entered into unlawful agreements, intentionally targeted prospective deals and knowingly or recklessly made false statements, they allowed the three antitrust claims alleging monopolization to stand.

Epic's spokesperson underscored that the court dismissed many of Particle's claims.

"Epic has worked and will continue to work to protect the privacy of patients' data while advancing interoperability," the spokesperson said.

In another prominent suit, Texas Attorney General Ken Paxton alleged that Epic "monopolizes" the EHR industry and restricts parental access to minors' patient portal accounts.

Echoing the Particle Health suit, the Texas AG also alleged that Epic controls data access, "despite the simple fact that it is the hospitals' and patients' data, not Epic's." Other allegations of anticompetitive behavior include limited interoperability with non-Epic EHRs and the imposition of penalties on customers who switch to any overlapping competitor applications.

But Epic has vehemently denied these allegations, highlighting its commitment to interoperability by virtue of its involvement in frameworks, such as Carequality and TEFCA. In response to the Texas AG suit, it also stated that its software "provides each customer autonomy over its own instance of Epic EHR software and whether to permit access to its data."  

In a recent email, the Epic spokesperson further noted that the action taken by the Texas AG "attacks" the practices that allow the company to serve its customers, including charging standard prices to ensure all customers are treated fairly, keeping them informed about Epic's development plans and protecting Epic's innovations.

"These aren't anticompetitive practices -- they're things we do so that healthcare organizations have predictable long-term costs and can plan for the future," the spokesperson said. "We look forward to presenting evidence to prevail in court."

Where does Epic's responsibility lie? 

While Epic has advanced interoperability in some respects, its wide-ranging influence gives it the power to undermine these efforts. But what does Epic owe to the industry at large?

Tisch noted that Epic's position in the health IT market is not unique, and there is precedent for its level of influence in other industries.

"From my perspective, it very much mirrors what we see in other dominant technology, marketplace-driven initiatives," he said. "And the ones that come to mind for me are Apple and their App Store, and also just Facebook. And if you look at both of those companies, there are many billion-dollar companies that have spun out of those marketplaces and ecosystems."

They're not a public utility. They collect a toll. We'd have to say to ourselves, 'Why would Epic cede that ground by themselves?'

For example, developers built billion-dollar businesses in Apple's App Store because Apple already owned distribution, payments, discovery and the user relationship, he added. Similarly, Facebook Marketplace gained traction because Facebook already had scale, identity and daily engagement, even though classified listings were far from a new idea.

"In healthcare, Epic has a similar advantage," Tisch said. "If you are already where clinicians work and where organizations manage core operational and clinical processes, you do not have to convince the market to go somewhere else first."

While dominant companies create convenience and distribution advantages that drive innovation and economic value, they hold significant sway over how participants access the market, he added. This is true for healthcare as it is for the broader technology market.

According to Tisch, what ultimately matters in the healthcare market is its customers. He said that it has always been a very customer-centric company, using customer feedback to guide development priorities.

But being a for-profit business means Epic's primary allegiance is to its customers and its own growth rather than publicly aligned interoperability efforts.

"They're not a public utility," D'Orazio said. "They collect a toll. We'd have to say to ourselves, 'Why would Epic cede that ground by themselves?' They clearly haven't. And I think they believe that what they do is right."

Epic certainly positions itself as a champion of interoperability. It can point to several initiatives it has spearheaded and participated in, from its Care Everywhere network and nationwide interoperability frameworks to the CMS Health Tech Ecosystem initiative.

For instance, the Epic spokesperson pointed out that Epic was the first EHR vendor to commit to TEFCA. Its customers were the first to share medical records with the Social Security Administration via TEFCA, speeding up access to care for Americans with disabilities.

Keeler also emphasized that other market pressures rein in monopolistic tendencies among EHR giants, including the healthcare information blocking rule established by the 21st Century Cures Act. The rule prohibits any practice that interferes with the access, exchange or use of electronic health information and requires access to that information through the use of APIs.

Every system-of-record market has dominant players of this variety, and only in healthcare do we have an information-blocking law that allows parity, allows equal technical access.

According to Keeler, the information-blocking rule protects the market from any egregious threats to interoperability posed by Epic.

"Every system-of-record market has dominant players of this variety, and only in healthcare do we have an information-blocking law that allows parity, allows equal technical access," he said. "The complaints that people have right now are already solved by this unique law in the book; that is my very hot take."

While all EHR companies, not just Epic, would act solely out of self-interest if they existed in a vacuum, the rule has recalibrated the industry to have a different default setting, he added. Now, if any EHR company exerts undue control over data exchange and blocks access, they risk violating the rule.

While the information blocking rule offers some guardrails, there is no doubt that Epic's scale gives it substantial influence over interoperability efforts. However, the problem is ultimately larger than any one company. Whether or not Epic is wielding its influence responsibly, its absence is unlikely to solve the issue at large. 

"I don't think it's fair to Epic to say that they caused this problem," D'Orazio said. "This was a massive problem. This is still a massive problem."

Anuja Vaidya has covered the healthcare industry since 2012. She currently covers the virtual healthcare landscape, including telehealth, remote patient monitoring and digital therapeutics.