People who are not software developers now build healthcare software with AI coding assistants, tools that write code from instructions typed in plain language. According to The 2026 benchmark for building with AI in healthcare, IT staff build with these tools at 84% of the organizations surveyed, against 58% for developers and engineers.

Paubox surveyed 151 healthcare leaders for the benchmark in July 2026, all from organizations already using AI coding assistants. At roughly two in five of those organizations, developers are not among the builders, and 80% have deployed AI-assisted tools to patients.

 

Who is doing the building

Operations and administrative staff build with AI at 53% of the surveyed organizations, compliance or privacy staff at 45%, clinical staff at 38%, and executive leadership at 36%. Over the past 12 months, 76% built six or more internal tools, scripts, automations, or integrations with AI help, and 70% expect AI-assisted development to increase over the coming year.

Nine in ten organizations cited faster development as a reason for adopting these tools. Clinical staff, the group with the least software training and the closest contact with patients, build at more than a third of them.

 

Why email ends up in the code

Appointment confirmations, intake receipts, result notices, and password resets are all common examples of transactional email, a message sent automatically when a user does something in an app.

Apps can send these messages through an email API, short for application programming interface, which lets one program ask another to do a job. Paubox's developer documentation lists send transactional email from an app as the main use for its Email API, with the app passing along the recipient, subject line, and message while the provider handles delivery.

 

What research shows about code written with AI help

Stanford researchers studied how people write security-related code with and without an AI assistant, using an earlier OpenAI model called codex-davinci-002. Participants with the assistant wrote insecure solutions more often on four of the five tasks. Encryption and SQL injection showed the clearest differences in the published version of the study, where SQL injection refers to an attack that slips harmful commands into a request sent to a database.

Participants using the assistant were also more likely to believe their code was secure, which led the authors to warn that these tools may give inexperienced users "a false sense of security." Those who trusted the AI less and reworded their prompts more often produced fewer vulnerabilities.

 

A provider that handles PHI is a business associate

HHS addressed cloud services in guidance published in 2016, stating that a provider maintaining electronic protected health information (ePHI) for a healthcare organization is a business associate. The status holds even when the data is encrypted and the provider has no key to read it.

HHS limited the conduit exception, which covers services like the postal service, to transmission with only temporary storage along the way. Using a provider to maintain ePHI without a business associate agreement violates HIPAA, according to the same guidance.

A business associate agreement, or BAA, is the contract in which a vendor commits to protecting protected health information (PHI). Amazon Web Services will sign one covering Amazon Simple Email Service, known as SES.

 

A BAA does not set the encryption

Paubox engineers ran 14 controlled tests against Amazon SES in the second quarter of 2026. Each result came from the message header, the technical record a receiving server adds to every email showing how it arrived.

Email moves between servers protected by Transport Layer Security, or TLS, and SES defaults to a mode called opportunistic TLS. In that mode, it attempts encryption and sends the message no matter the outcome, so when a receiving server offered no encryption, SES delivered PHI in plaintext that anyone intercepting it in transit could read.

Amazon's Require TLS setting closed one of the four failure modes tested. With the setting on, SES still delivered over TLS 1.0 and 1.1, versions retired in 2021, and it delivered all four test messages sent to servers with invalid certificates. A certificate is the credential a mail server presents to prove it is the intended recipient.

Hoala Greevy, founder and CEO of Paubox, said that "TLS being on is not the same as PHI being protected."

 

What the Paubox Email API does differently

Every message sent through the Paubox HIPAA email API is encrypted by default, and Paubox signs a BAA with every customer on every plan. Delivery requires TLS 1.2 or higher with a valid certificate, so a receiving server that can't meet that standard doesn't get the message.

Developers connect through official SDKs in ten languages, including Python, Node.js, Java, C#, and Go. An SDK is a prebuilt code library that handles the connection for the programmer, and apps that already send through a mail server can use SMTP, the standard protocol mail servers use to pass messages along.

Paubox publishes migration guides for teams moving from Mailgun, Postmark, Resend, SendGrid, and Amazon SES. Its documentation also includes OpenAPI specs, files describing every endpoint in machine-readable form, where an endpoint is a single address an app calls to perform one task. Paubox suggests pointing an AI agent or editor at those specs directly, so the assistant writing an integration works from the real API definition.

 

When an AI agent sends the email

An AI agent is an AI assistant that carries out tasks on its own, such as sending a message, rather than only answering questions. Model Context Protocol, or MCP, is a standard that lets those agents call outside tools, and Paubox runs an MCP server at mcp.paubox.com that lets Claude and other AI agents send HIPAA compliant email and work with Paubox Forms.

An API key works like a password that lets software use the Email API on an organization's behalf. Paubox keeps that key with the server process and never shares it with the AI model. Email sent this way is encrypted by the Paubox Email API, counts against the same plan, and shows up in the Paubox dashboard with the rest of the organization's API traffic, with a free tier covering 300 emails a month.

For AI-built software generally, the benchmark suggests reviewers ask "Was any part of this built with an AI coding assistant?" and route a yes into the same review and logging as any other software.

 

FAQs

Is an email provider a business associate under HIPAA?

Yes, when it maintains PHI for a healthcare organization. HHS guidance says this applies even when the data is encrypted, and the provider holds no key.

 

Does a signed BAA make email HIPAA compliant?

No. A BAA is a contract, and encryption depends on configuration. Paubox testing found Amazon SES delivering over retired protocols and to invalid certificates even with Require TLS switched on.

 

What is opportunistic TLS?

It attempts encryption and sends the message whether or not encryption succeeds. When the receiving server offers no encryption, the message travels in plaintext.

 

Can AI agents send PHI by email?

Through the Paubox MCP server, agents send through the Paubox Email API, which encrypts every message. The API key stays with the server and is never shared with the AI model.

 

Should AI-built tools get a separate review?

The Paubox benchmark suggests asking whether any part of a tool was built with an AI coding assistant, then routing a yes into normal review and logging.