#14A Waiting for Godot in Healthcare AI: Part I

In the 1952 play Waiting for Godot (Samuel Beckett, 1906-1989), Vladimir and Estragon are two tramps waiting by a road for the mysterious Godot. After debating whether and when Godot will come, Estragon says, “Let’s go,” to which Vladimir replies, “We can’t…we’re waiting for Godot.”

The tramps represent humanity: Vladimir the intellectual and Estragon the physical. The play shows how human life is changed by the letter that never came. The soldier who never returned and the knock on the door that never sounded. Their wait symbolizes humanity’s existential need for purpose, even in the absence of answers.

Systems of care seeking advanced AI applications for more precise medicine and equitable health are also in an existential pause, waiting for overheated markets to make AI-augmented human life more affordable and accessible. But without any real control over the factors of production — the GPU-powered data centers, agentic bots, and proprietary, highly curated databases —  humanity is left waiting.

And while we wait, our health systems are paying higher prices to train models with outdated AI tech while “building trust” with big EHR companies just to gain access to their patients’ own data.

Econ 101

In free markets, created by Adam Smith's invisible hand of self-interest, buyers and sellers set price and quantity without government controls. In such markets, companies compete for a share of revenues derived from the sale of a product or service to customers willing to pay a price (i.e., value-based). Sales may be spread across many companies, such that no single company can easily control price or output (i.e., a low concentration or crowded market). But when sales are controlled by a few dominant companies in a sector, they have great influence over what is sold and at what price it sells (i.e., a high concentration or oligopoly).

The Herfindahl-Hirschman Index (HHI) is the accepted measure of market concentration. HHI calculations simply square the market share of each firm competing in a sector, then sum them to produce total HHI points. HHI approaches zero (low concentration) when a sector is occupied by many firms with relatively equal market share and can reach a maximum of 10,000 points (100% x 100%) when a market is controlled by a single firm (i.e., a monopoly). HHI increases as the number of firms competing in the sector decreases and as the disparity in the size of market share between firms increases. While there is no normal level of market concentration, the DOJ views markets as being "moderately concentrated" when HHI = 1,000-1,800 points and highly concentrated when HHI is >1,800 points.

While not illegal per se, high market concentration (see Table 1) can lead to higher prices, less output (i.e., less innovation), and fewer choices for consumers (i.e., less competition). High concentration also changes how companies behave. The major players often watch each other closely for pricing (or discounting) actions while making strategic decisions to influence market competitiveness through supply & demand dynamics.

AI 101

The AI business sector is extremely complex, dynamic, and highly concentrated (see Table 1). AI market concentration is reflected by sales revenues of the leading firms, and by the fact that >50% of the U.S. stock market's return (profits) is accounted for by the magnificent seven companies: Apple, Microsoft, Alphabet, Amazon, Nvidia, Meta, and Tesla. The Russell 1000 Index has seen its HHI grow rapidly since 2015. Such high concentration poses risks to active stock market investors and consumers.

For consumers, the lines between what companies have traditionally sold (goods and services) are becoming blurred, especially when there is concomitant rapid market growth (driven by high demand) perpetuating concentration. In the AI tech sector, this situation is exemplified by the overlap between cloud computing (infrastructure), data centers (power and chips), consumer-facing chatbots, and agentic software for business.

Of note, the most extremely concentrated market is GPU-powered data centers, the sector underpinning accelerated development and scaling of GenAI systems. Nvidia has >81% market share, while its closest competitor, Advanced Micro Devices (AMD), has 10% (combined HHI points = 6,661). Effectively, this is a monopoly, although CPU-powered data centers are attracting more clients (Microsoft grew related revenues by 7% in Q2 of 2026).

EHR: A Special Business Sector?

The electronic health record (EHR) business is a rapidly growing multibillion-dollar sector. EHR is the digital health information technology (HIT) infrastructure at the core of most health systems' day-to-day clinical operations and business development strategies.

EHR market growth has traditionally been driven by personal health information (PHI) privacy and security mandates (HIPAA, etc.), and via EHR solutions for health systems' critical cross-functional interoperability needs (i.e., in-/out-patient care coordination, revenue cycle management, image archiving [PACS], telehealth integration, etc.). The EHR acute care hospital market is highly concentrated (see Table 1), with two large vendors forming a duopoly — Epic Systems Corp. (38-43.9%) and Oracle-Cerner Health (18.9-22%) [KLAS EHR Market Share Report, 2026]. Epic gained 77 hospitals in 2025 (growth), while Oracle lost 56 hospitals (attrition), reflecting ongoing market concentration.

Past drivers of EHR sector concentration:

• Legal: The HITECH Act (2009) required health system industry-wide digital migration onto enterprise software platforms (eliminating smaller vendors).
• Financial: Massive switching costs to implement a new EHR system (favoring incumbents).
• M&A: Hospital consolidations into mega-health systems requiring systematic conversion to a common corporate EHR platform.

Author 

— by Doug Miller, MD, Professor, Department of Medicine: Cardiology, Department of Artificial Intelligence & Health, Department of Radiology and Imaging, Medical College of Georgia, 9/2026

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