Elion has published The AI Governance Playbook: Insights and Tools for Building Oversight That Works, offering an in-depth look at AI governance in major U.S. health systems. The report shows that as requests for AI projects increase across clinical and operational areas, many health systems are struggling to keep pace with effective oversight. While around two-thirds of systems involve 15 or more staff members in governance activities, more than 75 percent rely on only one or two full-time employees to manage the program daily, creating significant strain on resources.

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Despite investments over the past 12 to 18 months to establish governance programs, submissions for AI projects now exceed committee capacity, leaving nearly three projects pending for every two reviewed. This imbalance slows deployment and puts additional pressure on operational leaders who are responsible for maintaining safe and responsible AI integration.

“Health systems have built governance frameworks, but they are quickly realizing that these structures need more staffing, faster decision-making, and broader scope to meet real-world AI demand,” said Bobby Guelich, CEO and Co-Founder of Elion. “As AI becomes embedded in more aspects of care and operations, governance processes must evolve or risk losing meaningful oversight.”

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Interviews with leaders from more than 20 leading health systems along with a quantitative survey reveal three major factors driving the backlog. First, the volume of AI projects is rising faster than governance can handle, with most systems receiving four to six new submissions per month but only completing fewer than three decisions. Second, staffing remains insufficient to manage these initiatives, as most systems operate with very limited dedicated personnel. Third, more than 60 percent of leaders report that available resources are inadequate for ongoing monitoring and local validation. As AI spreads across documentation, clinical decision support, scheduling, claims management, and imaging workflows, the need to scale governance beyond ad hoc committees has become urgent.

The Playbook also includes a toolkit developed with Dr. Sarah Gebauer of Validara Health, a physician and AI researcher. This toolkit highlights early best practices and provides practical templates, including intake questionnaires, risk-tiering matrices, and contracting considerations to support health systems in building effective and scalable AI oversight.

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