[WesBrownSQL]

1. Certification, in the USA if you want to get paid from the government you must be certified. This isn't a small undertaking at all and requires quite a bit of development and then the cost of actually doing the third party testing. It has driven companies out of business and forced consolidation even among the larger players.

2. Configurability. EMR's are crazy configurable to meet any hospitals requirements. This means lots of consultant hours to get things setup and running. Take a look at how much money Epic and Cerner make just from "consulting".

3. Interoperability. Again, there are standards like HL7 and FHIR are widely used but the data isn't always great. We are seeing more and more API endpoints all of this requires a level of customization.

All of this adds up to a ton of cost for a small-ish market with a large pool of no or low profit buyers and pretty much a replacement market.

Oh, and you are building software that could cause harm or death. I can't imagine why people don't want to come into this industry and really push the state of the art.