We systematically assess the performance of three leading API-based de-identification systems - Azure Health Data Services, AWS Comprehend Medical, and OpenAI GPT-4o - against our de-identification systems on a ground truth dataset of 48 clinical documents annotated by medical experts. Our analysis, conducted at both entity-level and token-level, demonstrates that our solution, Healthcare NLP, achieves the highest accuracy, with a 96% F1-score in protected health information (PHI) detection, significantly outperforming Azure (91%), AWS (83%), and GPT-4o (79%). Beyond accuracy, Healthcare NLP is also the most cost-effective solution, reducing processing costs by over 80% compared to Azure and GPT-4o. Its fixed-cost local deployment model avoids the escalating per-request fees of cloud-based services, making it a scalable and economical choice. Our results underscore a critical limitation: zero-shot commercial APIs fail to meet the accuracy, adaptability, and cost-efficiency required for regulatory-grade clinical de-identification. Healthcare NLP's superior performance, customization capabilities, and economic advantages position it as the more viable solution for healthcare organizations seeking compliance and scalability in clinical NLP workflows.

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