The Information Exchange

HTD Health

A not-a-podcast video series about health tech's chess moves and the bigger picture for tech as a whole. Brought to you by the HTD Health team healthapiguy.substack.com

  1. 13 Jul

    The Information Exchange: The Epic Quadrumvirate

    Welcome back, folks. We are joined by a fresh new face and voice this week: Bryan Fowler (a.k.a. Brydawg, Bryster, B-man, first of his name, Lord of Coding and the HIM Department) joins for his first episode while Ryan and Pryce sit this one out. Bryan brings Epic and Datavant experience, Cleveland residency, and cautious optimism about a LeBron boomerang. Fitting, because the main event this week is Epic’s own succession story. Sumit Rana, long presumed heir to Judy, announced his departure in the all-time pre-July-4th news drop. We work through the push and pull factors, from the stated family reasons to the AI gravitational field to the growing pile of depositions, and then break down the four leaders Judy named in response. Along the way: an explainer on Jodel, the anonymous app where Epic’s internal commentary actually lives. From there, Bryan brings Don Rucker’s recent podcast claim that patient matching is a solved problem, which holds up fine for eligibility flows and less fine for everything else. We close on a few angles of what is looking to be a fun regulatory fall: * The Unified Agenda has reappeared after a long absence with an August date for HTI-5 finalization * The EHR Association’s spring article feels like it’s building a paper trail for a procedural challenge * HTI-6 looms in November with FHIR subscriptions potentially in scope. All that and more. Relevant Articles * The Cleveland 2016 championship mural: Will he go home? * The Epic Abdication: The full succession deep dive: the trust structure, the trust protectors, the developer requirement, and why one resignation email is the most consequential personnel event at Epic in years. * The Markets Knew: The succession market as if it was on Kalshi (it’s not) * An Epic Anthropic Alliance: The original article about Jodel, as well as Epic’s use of Claude * The State Shows Its Hand: Texas's witness list in Texas v. Epic, where Sumit, Judy, Seth Howard, Stirling Martin, and Fritz Schmidt all appear. Context for the deposition burden discussion. * Out of the FHIR: The Illusion of Interoperability: The podcast appearance where Don Rucker makes the case that patient matching is largely solved, the claim Bryan brings to the table this episode. * The Burgerservicenummer: Centralized patient ID has some upsides. * HTI-5: When the Scorpion Learns to Swim: The original proposed rule breakdown: certification pared back while information blocking sharpens, RPA and agents squarely in scope. * The Malpractice Bar v. the Deregulation Agenda: The HTI-5 comment period closes with a trial-lawyer form letter flood, plus HTD's eight-section letter. genda: * An Argonaut Miss?: The six jobs of a point solution integration and why the ONC just adopting the Patient Data Feed wouldn’t solve the biggest problems in sight for the industry. * A Shot Across the ONC's Bow: The EHRA's "Information Blocking Red Flags" post, what changed between their February comment and the blog, and the missing burden estimates that read like litigation groundwork. * The Regulatory Roadmap Reappears: The full read of the 2026 Unified Agenda: three editions in a trench coat, the maple syrup identity rule, the HIPAA care coordination rule back from the dead, and the HTI-5 and HTI-6 dates. * The Invisible Agenda: Chapters * Intro and a New Voice (0:00 – 0:56): Bryan Fowler joins the show for the first time. Cleveland, the 2016 championship mural, and whether LeBron comes home again. * Sumit Steps Away (0:56 – 9:09): The heir apparent leaves Epic in a pre-holiday news drop. The stated family reasons, the AI pull toward OpenAI, Anthropic, or Microsoft, the deposition burden, Epic stock up 33% in February, and an explainer on Jodel, where the Epicverse actually talks. * The Quadrumvirate (9:09 – 15:52): The Kalshi field (Seth Hain, the winners, the public faces) versus the developer-background requirement, and the four Judy actually named: Seth Howard, Erv Walter, Mark Lipsky, and Garrett Adams. Race, grooming exercise, or temporary measure, with UGM a month away. * Patient Matching and the Burger Social Number (15:52 – 23:52): Don Rucker says patient matching is basically solved. True for eligibility flows built on a shared member ID, less true for longitudinal care. National identifiers, CLEAR and ID.me at the TEFCA and MyChart edges, the Netherlands’ BSN, Brad’s unmergeable CVS accounts, and the two flavors of fraud. * The Agenda Reappears (23:52 – 30:57): The Unified Agenda emerges after a year of silence as a single 2026 airdrop. Maple syrup identity from the FDA, an August date for HTI-5 finalization, and the EHR Association’s blog series flagging missing burden estimates, which reads like groundwork for a procedural challenge. * HTI-6 and the Enrollment Problem (30:57 – 37:15): November’s proposed rule could bring FHIR subscriptions, CDS Hooks, and API-forward certification criteria. Why subscriptions matter most for provider point solutions, and why Argonaut’s Patient Data Feed targets supplementation events when the big four enrollment events (patient created, encounter started, appointment scheduled, order placed) are the actual gap. Also a Moana detour. Transcript We ran the transcript through an LLM to smooth it out. So it’s a rough approximation of the conversation (and in many cases significantly clearer than our rambling), but notably diverges from the word-by-word blows quite a bit. Brendan Keeler (00:00): All right, we’re back. But we got someone new today. Mr. Bryan Fowler joining us for the first time. Ryan and Pryce unable to make it. So Bryan, welcome. Do you want to say hi to the audience? Bryan Fowler (00:09): Yeah, thanks. Bryan here, new to the HTD team, really excited to be here. Spent some time at Epic in the past as well as Datavant, so looking forward to all the cool things we’ve been doing here. A little about me: I’m in the Cleveland area now, working on healthcare interoperability. Brendan Keeler (00:27): And newish, given you joined in Q1, but we’ll count it. New guy for the time being, for at least a few more weeks. The big question, definitely interop focused in nature, because it connects to you: is LeBron coming back? Bryan Fowler (00:31): Gosh, fingers crossed. The 2016 championship was big. Cleveland recently redid a mural of the 2016 championship team. Seems unlikely, but there’s still a chance, and if there’s a chance, we’re waiting for it. Brendan Keeler (00:56): That would be fun symbolism. For me: let’s go Sixers, let’s go Birds. But on to the actual interop of the day. Well, not really interop. More Epic news, and big news that shook the industry. Sumit Rana, the senior leader, the proposed heir to Judy at Epic, leaving in the all-time pre-July-4th drop. Everyone’s checking out for the holiday and all of a sudden it’s: go check your phone, there’s a disturbance in the force. Anyone have thoughts or takes? Brad Thorson (01:28): As the only non-Epic person on the team, and also the only person from Wisconsin, I feel like I’ve got a little perspective. Never met Sumit, and I definitely think there could be some Succession-level machinations behind the scenes, but we should leave open the chance that Epic has been massively successful, probably compensated their executives pretty well, and some people just really want to be on a beach. I’m here if drama comes out, though. What’s interesting: Judy loves the power of three. I remember she had three people that were going to take over, ownership-wise, after she passed. And now she’s selected three people. Brendan Keeler (02:14): Four. Brad Thorson (02:15): There’s a fourth? Okay, now you gotta run me through it. What did I miss? Brendan Keeler (02:18): Well, before we do: Bryan, any quick takes? Bryan Fowler (02:22): Coming from Epic, this is a really big shock. Sumit has been a really present personality, with conferences, with public speaking. He generally fits the mold of expectations for succession: a background in software development, really prominent in the Epic ecosystem and the community. So seeing him leave, on such short notice, is definitely a shock. I almost wonder, just like LeBron, are we looking at the biggest boomerang in Epic history? Come back as CEO, something crazy like that. Brendan Keeler (02:58): That’s definitely been surmised by some people. The stated reason for leaving was that his father passed last fall, that he’s going back to India, where he grew up, to be with his mother and family for some time. We can all be sympathetic to that story and should at least assume it’s a part, if not the major part, if not the whole part of the story. But generally something so abrupt takes multiple small pushes, or big pushes, or pulls. And you could imagine, in a corporation like Epic going through a tumultuous time, with the litigation, with the pressure from digital health, with administrations that have trended from the Meaningful Use era, where administrations looked to cater to EHRs and gain their favor and collaborate with them, toward a more pejorative view of them as entrenched incumbents. “Why did we do Meaningful Use?” That sort of sentiment. You could imagine pull toward greener pastures, particularly of the AI variety. So people have posited OpenAI or Anthropic or Microsoft as an eventual destination for him, as he was, by all accounts from some employees, AI-pilled. Brad Thorson (04:10): Big into Anthropic, right? Brendan Keeler (04:12): Well, they adopted Claude en masse. They’re heavy Claude users internally, so there’s a relationship there. Microsoft is part of their stack, so there’s a relationship there. I don’t put it at a high chance necessarily, but it certainly seems possible. Brad Thorson (04:27): You say there are probably a lot of little pushes that lead to a big announcement like this. It’s not a particularly leaky organization. So what was that strange employee feedb

  2. 4 Jul

    The Information Exchange: Hot Dog CarePlan Resource Edition

    Fresh off that sweet, sweet USA win and headed into the long weekend, the full crew assembled for our most patriotic episode yet. Have you ever yearned for a podcast with Fourth of July interop trivia? Look no further, friend. Beyond that, we do (eventually) get to the real agenda: * The ONC awarded a TEFCA auditing contract to Alliance Global Tech, a DC contracting firm nobody in the health tech bubble had heard of. * We work through what the contract actually covers, why the RCE was probably as surprised as everyone else, and whether an outside auditor with no industry baggage is a feature or a bug. * Along the way we review AGT’s website redesign, which traded glorious 2000s-era stock-photo patriotism for AI slop on the eve of the country’s 250th birthday. From there, predictions. Does information blocking enforcement land by end of year? Who gets hit first? Plus Brad’s corp dev forecast for a pre-midterms consolidation rush, year two of the CMS Health Tech Ecosystem, and what HTI-6 might absorb from the pledge-a-thon. Fair warning: none of us are lawyers and none of this should be construed as legal advice. There is, however, a defensible argument that a hot dog is a medication. As promised: { "resourceType": "CarePlan", "id": "hot-dog-care-plan", "status": "active", "intent": "plan", "title": "Hot Dog Care Plan", "subject": { "display": "Joey Chesnut (DOB 1983-11-25)" }, "period": { "start": "2026-07-04", "end": "2026-07-04" }, "activity": [ { "detail": { "kind": "NutritionOrder", "status": "scheduled", "code": { "text": "Hot dog (frankfurter), oral route. OMD in HL7v2, NutritionOrder in FHIR, a nurse and a side web panel in reality." }, "dailyAmount": { "value": 70.5, "unit": "hot dogs", "system": "http://unitsofmeasure.org", "code": "{hot_dogs}" }, "description": "Ask upon order entry: what do you want on it? Mayo permitted for documented sickos only. Fax to hot dog guy." } }, { "detail": { "kind": "ServiceRequest", "status": "scheduled", "code": { "coding": [{ "system": "http://hl7.org/fhir/sid/icd-10-cm", "code": "Y93.G2", "display": "Activity, grilling and smoking food" }] }, "description": "Pursue Y93.G2. Do not pursue W39.XXXA (Discharge of firework, initial encounter). Ask Jason Pierre-Paul." } } ], "note": [{ "text": "Supportive therapy: one schnatton of water per hot dog. UCUM does not define the schnatton. Neither do we." }] } Let’s dig in. Relevant Articles * Murica: The European mind cannot even begin to comprehend * June Monthly Review: The Unusual Suspect: The full writeup on Alliance Global Tech, from the contract record and credential wall to the case studies that are secretly job postings. * Outgoing Diet Orders HL7v2 Specification: Receipts for the hot dog segment. Diet orders are real, and there's an interface for them. * The Information Exchange: The TEFCA Report Card: Last time we graded TEFCA itself; this week the network got a new proctor. * SEC Budget: Government agency, not the NCAA conference. Actually $1.9 billion. * The Arena Expands: Abridge's land grab across the clinical copilot jobs to be done, background for Brad's consolidation prediction. * The Shape of 2026: Circling back on some HTI-6 predictions Chapters * Intro and the Most American Standard (0:00 – 4:01): Fourth of July interop trivia. Brad nominates fax, Ryan makes the melting-pot case for CCDA, and Pryce disqualifies HL7 on governance grounds. * Prescribing a Hot Dog (4:01 – 8:43): Pryce builds a SMART app for condiment selection, Brad gets caught Googling, and diet orders turn out to exist: OMD in HL7v2, NutritionOrder in FHIR. Joey Chestnut’s chart may require careful unit validation. * ICD-10s for the Fourth (8:43 – 10:42): W39.XXXA, discharge of firework, initial encounter. The one to pursue instead: Y93.G2, grilling and smoking food, which absolutely Pryce nails. * TEFCA’s New Hall Monitor (10:42 – 16:50): The ONC awards a TEFCA auditing contract to an outsider and half the industry misreads it as Sequoia being replaced. The $1.8M contract, the 70-hospital letter, and Brad asking why thirteen QHINs exist if nobody polices their own network. * Alliance Global Tech, Reviewed (16:50 – 22:31): Who won, the TEFCA support page they posted and pulled, and the promise of AI-assisted fraud detection. A moment of silence for AGT’s old website. Impartiality costs expertise, but at least someone is taking a shot on goal. * Information Blocking: Who Gets Enforced First? (22:31 – 31:52): Will enforcement land by end of year? Brendan predicts end of summer with Epic as the politically satisfying target, though the egregious blocking lives down market. Plus whether PointClickCare’s preliminary injunction counts as a proven case (it doesn’t). * The Homer Defense (31:52 – 35:03): Why Epic is the most accused and least guilty information blocker, per aggregate client experience with the Manner Exception. Pryce invokes Hanlon’s Razor. Nobody on this call is being paid by Epic under the table, allegedly. * Second-Half Predictions (35:03 – 41:10): Brad forecasts a consolidation rush before midterms, with certified health IT as radioactive M&A inventory. Year two of the CMS Health Tech Ecosystem, HTI-6 absorbing what the ecosystem proves out, MA plans instituting IAS, and Ryan’s line drive down the fairway. * Sign-Off (41:10 – End): Happy Fourth. Go get that hot dog, stay away from the fireworks. Transcript We ran the transcript through an LLM to smooth it out. So it’s a rough approximation of the conversation (and in many cases significantly clearer than our rambling), but notably diverges from the word-by-word blows quite a bit. Brendan Keeler (00:00): Alright, we’re back. Just yesterday there was the big win. USA. USA. Perfectly timed as we head into July 4th weekend. The four of us are here, and we’re going to kick things off a little different: some Fourth of July interop trivia. I have questions prepped for you all. Brad Thorson (00:19): Trivia feels like a stretch, but let’s do it. Brendan Keeler (00:25): We’re combining our two favorite things right now, America and interop. First one: which interoperability standard is most American? Ryan Tucker (00:35): I think our patriotism could have been displayed a little better here. I’m a little disappointed. I’ve got the red, white, and blue. Brendan’s kind of got the red. At least you mentioned the USA, although I have not watched the World Cup at all, which I think is very American, actually. We’re not a soccer nation. Brendan Keeler (00:51): It’s tough. It’s balancing two of our favorite things: winning on the one side and hating futbol on the other. Brad Thorson (00:57): Meanwhile, I’m the real football fan here. Guys, the most American interoperability standard, this is so easy. It’s fax. Brendan Keeler (01:11): That’s a good candidate. It’s ubiquitous and everyone has it. Brad Thorson (01:16): You are manifest destiny. Get the wagon and just head west with your fax. Ryan Tucker (01:25): I feel like fax and its ubiquity is more like an empire. The Roman Empire, or England when they had so much of the world. I don’t know if the US, with its isolation versus the entire rest of the world, makes sense there. Brendan Keeler (01:46): Well Ryan, what do you got? What standard is most American? Ryan Tucker (01:49): Maybe CCDA. I don’t know if I’m biased because I was on the Care Everywhere team, but CCDA is just: throw it all in there. You’ve got everything covered, all your bases, all fifty states, you’ll find something. Brendan Keeler (02:05): So it’s the melting pot. The melting pot of standards. Ryan Tucker (02:08): Exactly. It’s got the most diversity. It’s also sometimes the loudest and most difficult to deal with, which I think gets brought up when Americans go abroad. That’s what I’d throw in the ring. Brendan Keeler (02:24): Those are big payloads, and we like big. Okay, Pryce, what do you got? Pryce Ancona (02:32): I need to disagree with all of that. I’ve got this amazing swag, a little Lego server from the FHIR DevDays conference, and let me remind you: it’s HL7 International. HL7 CDA is an HL7 International standard. So I’m pushing back, especially on FHIR. We’ve got Australian Grahame Grieve leading the charge there, with all due respect to him. I’m trying to decide between X12, which I hate, but is statutorily required, so Capitol Hill has literally talked about it, or NCPDP, the National Council for Prescription Drug Programs. Brad Thorson (03:24): I thought you were going to say NCPDP. I was literally Googling whether it has any international adoption before you even said it. Brendan Keeler (03:36): I’ll play judge here, and I gotta say: it’s X12, baby. Show me the money. I had X12 written down. HL7 DFT was a great choice too, also money, but international in flavor. X12, we do our own thing. Everyone else does GS1. And it’s pretty ubiquitous. So Pryce, this one goes to you. Brendan Keeler (04:01): Next question. That one was big and strategic; this one’s more tactical. If a doctor was prescribing a hot dog, what would be the appropriate data format? Pryce Ancona (04:15): Ooh. ServiceRequest, MedicationRequest, ORM, NCPDP. The first thing I think of when you order a hot dog is: what do you want on it? Especially if you’re ordering from a real hot dog person. You don’t just get a hot dog and then put ketchup on it. It feels very New York. So maybe there’s a clinical decision support rule that triggers a SMART app window with a bunch of ask-upon-order-entry questions. Do you want ketchup, mustard, sport peppers? And then fax it to the hot dog guy, I guess. Brendan Keeler (05:01): You’re thinking of the Epi

  3. 9 Jun

    The Information Exchange: What Is Treatment?

    Should The Information Exchange be renamed Interoperability Office Hours? Last episode we graded TEFCA. This time we’re reviewing homework of our good friends Quinn Emmanuel and Cravath in Particle v. Epic and answering some of the meatiest health information exchange questions of our time. After Judge Buchwald let some claims survive Epic’s motion to dismiss last fall, she did something unusual: rather than open the floodgates to full discovery, she carved out a limited Phase I focused entirely on market definition. But when time was up at the end of May and that didn’t really solve the problem, she doubled down and handed both Particle and Epic a take-home exam. So Pryce, Brad, and I sat down to read each student’s answers: * What is a payer platform, and is there even a market for one (that just includes Particle and Epic)? * What separates a payer from a payvider from a provider, and does anyone actually like the word “payvider”? * When do operations and treatment converge, and why does the pricing gap between the two distort everything around it? We work through all ten questions, the redactions hiding the spicy parts, and what we think Buchwald does next. Fair warning: none of us are lawyers and none of this should be construed as legal advice. However, there’s a sustained rant about arbitrage, and at least one antitrust doctrine gets renamed the “Pryce Ancona break-things” test. Let’s dig in. Relevant Articles * The Take-Home Exam: Summarizing the assignment from Judge Buchwald to Particle and Epic a few weeks ago. * The Doggy-Bag Era of Content: On LLM verbosity and the need for brevity in this era * A River Runs Through It: * Particle v. Epic: The Grandaddy Lawsuit Returns: The first post after Phase I concluded, looking ahead at what’s to come * Older related content * Epic v. Particle: The original summary of Epic and Particle’s Carequality dispute * Epic v. Particle 2: The Problem of Secondary Use: A followup to the above that focused on secondary use and its role in the conflict * The Particle v Epic Casebook: A summary of the case proceedings in October * Amber, Stenotypes, and Antitrust: Epic losing its motion to stay discovery in CureIS, which we were sure Epic was jealous of Chapters * Intro and the Take-Home Exam (0:00 – 4:49): The crew swaps the usual format for a graded exam. Background on Particle v. Epic since September 2024, the surviving antitrust and tortious interference claims, and why Buchwald, skeptical of the alleged market, wants five pages from each side in plain English. * Q1: What Is a Payer Platform? (4:49 – 11:39): Whether Epic Payer Platform and Particle’s product are substitutes in a single market. Pryce’s CDA-to-chart-summary walkthrough, payers paying out the wazoo for treatment-rail data, and the hammer-versus-mallet question of whether a product market exists at all. * Q2: Payer, Payvider, Provider (11:39 – 16:31): Provider is the easy one, payer is the financial risk bearer, and payvider is the term nobody will commit to under oath. Epic disowns the word, the Apple hardware-or-software analogy, and the two-instances-of-Epic compliance boundary. * Q3–Q5: Customer Mix and Active Role (16:31 – 21:24): Particle claims 100% VBC payers and payviders; Epic backdates 23 payer customers plus provider users as a wrinkle. Q4 discovery is a wash, and Q5 on whether a pure payer takes an active role in member health is really question two in disguise. * Treatment, Operations, and the Arbitrage Rant (21:24 – 29:38): The trench-coat problem with payvider, the HIPAA operations definition and HEDIS, and Pryce’s river separating treatment from operations. Brendan’s side quest on pricing treatment exchange at zero while operations pays market rate, and the incentive to abuse the networks. * Q7–Q8: Same Customers, Same Products? (29:38 – 33:44): Whether EPP and Signal serve different customers in different ways. Particle says any differences are implementation detail; Epic says Signal runs one-way over Carequality for treatment while EPP can’t even reach Oracle or Athena. Barrier to entry and whether explaining it this simply undercuts the two-player market. * Q9–Q10: Purpose of Use and the Break-Things Test (33:44 – 37:18): Whether HIPAA purpose of use defines a product market. The Pryce Ancona break-things test on reasonable interchangeability, Epic turning Particle’s Innovaccer argument back on EPP, and the extra-credit treatment question buried under redactions. * Grading the Exam (37:18 – 40:46): Buchwald as philosopher of treatment and operations. Brad finds Epic’s market definition more compelling, Pryce thinks they’re splitting hairs, and Brendan predicts summary judgment against the antitrust claim with the tortious interference count surviving to narrower discovery. * Spurs, Knicks, and Sign-Off (40:46 – End): Playoff trash talk and a closing nod to the underdog in both the court case and the NBA. Transcript We ran the transcript through an LLM to smooth it out. So it’s a rough approximation of the conversation (and in many cases significantly clearer than our rambling), but notably diverges from the word-by-word blows quite a bit. Brendan Keeler (00:00): Right. We’re back. And you know, we did the TEFCA episode last time. We’re gonna change up the format. We’re gonna do an exam. Namely Judge Buchwald’s exam, which she gave to two of the leading health tech companies out there today, Particle and Epic. This is a long time coming. This case has been progressing since September 2024. Made it through a motion to dismiss, with some of the claims being knocked out, but the antitrust claim, some of the antitrust claims, and a tortious interference claim making it through to the next phase. However, Buchwald scrunched it and said, hey, discovery is not gonna progress in full. Instead, you’re just gonna prove to me that we can actually figure out what a payer and a provider are, what treatment is, whether there’s an actual market here for a payer platform. Because the key assertion from Particle in their antitrust claims is what is the relevant product market, and the product market asserted is this payer platform that they asserted only Epic and Particle had. That’s been going since last September, 2025. We’re exiting Phase 1 and there’s still a fight. And Particle and Epic are pushing for motion for summary judgment by Epic, pushing for actual full discovery by Particle. And Judge Buchwald has concluded that they’re just restating the same things that they did last fall, and she needs a five-pager from each of them on these key questions, with as little industry jargon as possible. So what do you guys think it means when a federal judge has to ask these tech companies to explain their own products in plain English? What does that say to you? Brad Thorson (01:48): I mean, I don’t know how long the typical litigation process is in healthcare, but it’s pretty clear she doesn’t want to be caught in this for another five years. And that there’s, you know, circular definitions. It just screams of like, can we just call X X and Y Y, and nobody is willing to say we agree on these, except for, we will say treatment is specifically this particular clause in HIPAA. Aside from that, let’s all just create our own definitions. So you can just hear her frustration. And as somebody who’s not involved in this at all, it’s pretty funny. Brendan Keeler (02:26): Pryce, what do you think? Pryce (02:26): This is a teacher to me. I’m getting a teacher who’s like, that’s an interesting explanation. Make it an eighth as many words and make it much clearer and then maybe I’ll think that you did a good job. Brad Thorson (02:29): It did not feel gentle. This felt very much like everybody shut up and just say what you want to say. I’m reading “See Me After Class.” Pryce (02:55): Yeah, exactly. Which is awesome. Nowadays, you know, with generative LLMs and things like that, everyone can say everything all the time, as many words as they want, as confusing as they want. SAT words are a dime a dozen. But when someone says, I want you to be able to explain this to my mom or something like that, I know I’m doing a good job of teaching if I can explain a concept from our industry to my mother who doesn’t care about our industry. And so I love the idea that it’s like, let’s distill this. I want you to say this as plainly as possible, because it’s giving a hint of like, both of you are trying to mask what you actually believe. So now choose your words carefully. And I’m excited to dive in. Brad Thorson (03:45): Have either of you seen Succession? Pryce (03:48): A little bit. Brad Thorson (03:49): There can be like seven-minute scenes where multiple characters are talking about something and there’s no way to discern what the hell they’re talking about. It is just word buzz salad. Whatever happens with LLMs in the legal profession, I’m betting that Quinn Emanuel lawyers have an opportunity to write on the Succession reboot whenever we’re ready. Brendan Keeler (04:12): One, “brevity is the soul of wit” is now “brevity is the soul of liveliness.” And Judge Buchwald is internalizing that and hoping that gets us through here. I’m also just, before we dive in, doubtful, right? The whole case is predicated on them having different opinions about what the product market definition is and being like, hey, please just come to an agreement about it. Doesn’t seem likely. Pryce (04:31): Well, did she expect agreement, or did she expect them to actually just have to paint with primary colors and then we’re gonna see that one is red and one is orange? I guess those probably aren’t both primary colors, but they’re different. And that’s worth seeing. Brendan Keeler (04:49): For sure. They have responded, but before we do that, let’s just walk through the questions and talk th

  4. 26 May

    The Information Exchange: The TEFCA Report Card

    We are back, but we’re trying something a bit different this time. Given a little Memorial Day lead-up lull afflicting the industry, we decided to give a primer and run-down on the successes and failures of America’s only statutorily blessed nationwide health data exchange: TEFCA two years in, with what's actually working, what isn't, and what the rails really do at this point. Lot of fun this not-a-pod: * The first iteration of our new “Pryce Transparency” segment * Brad as a Trusted Exchange Guinea Pig * Five generations of patient access policy and technology in five minutes * Where Epic stands alone on a FHIR flow that's now an exhibit in active antitrust litigation. * The authentication vs. authorization debate that's becoming the most consequential architectural question in patient access. * Diagnostic imaging’s role in all this (and interop broadly) And of course, what we’re putting on our Memorial Day burgers. Hiring Notice HTD is hiring! We are looking to bring on Associates to our Interoperability Practice. If you have experience with EHRs, interoperability, and/or consulting and want to: * Work on the deepest, darkest arts of integration and health information exchange * Help the full range from startups to the largest tech companies in the country understand and play in the interoperability landscape * Help EHRs become their better selves (both via collaboration and pressure) * Learn and use regulation deeply as a strategic lever to enable the businesses we work with * Collaborate with a scaled development team across multiple geographies (US, Poland, Argentina) Then respond to this email with your resume and the one big interoperability problem in America you’d solve if you were a policy maker. Relevant Articles * HTI-5: When the Scorpion Learns to Swim: We briefly discuss how HTI-5 is proposing to remove the main “incentive” to join TEFCA, the TEFCA Manner Exception. * Individual Access Services Open Forum: An oldie but goodie primer on how Individual Access Services works and the history behind it. * The Rise of Consumer Health On-Ramps: Detail about the “Big 4” consumer health and patient access on-ramps * Epic’s IAS Implementation: A rant from a year ago about frustrations with Epic’s Individual Access Services implementation * JG Wentworth: Pryce’s mention was like a sleeper activation codeword for me. Real nostalgia rush. * Authorization Tradeoffs: A chart I made when discussing the tradeoffs of different authorization architectures * SMART Imaging Access: Josh Mandel’s reference implementation for patient access to diagnostic images that we talk about * Much Ado about Diagnostic Images: Discussion of the ONC’s RFI on Diagnostic Imaging and a detailed overview of the space * AADJ v. Epic: The Motion to Dismiss: The antitrust case against Epic related to TEFCA IAS Chapters * Intro and HTD Hiring PSA (0:00 – 0:44): Brendan, Pryce, and Brad pitch HTD’s interoperability associate roles across EHR integration, HIE, payers, clearinghouses, and information blocking strategy. * Pryce Transparency (0:44 – 3:19): A foundational walkthrough of the Trusted Exchange Framework, QHINs as the Verizon and AT&T of federated clinical data, and the difference between treatment queries and Individual Access Services. * Measuring TEFCA Against Itself (3:19 – 8:06): Adoption looks lukewarm next to Carequality on document volume, but two years ago IAS was zero. Pryce’s broken query to his Athena PCP illustrates the fingerprinting problem when something fails and no one can tell whose fault it is. * Five Generations of Patient Access (8:06 – 15:35): From HIPAA right of access through View Download Transmit, scrapers, Cures Act G10 APIs, and now IAS. Each generation solved the prior bottleneck and surfaced the next. Portalitis, Kristen Valdez’s term, and why IAS still falls back to G10 like Apple Pay falls back to cash. * Diagnostic Imaging and the Limits of TEFCA (15:35 – 21:31): Brad’s CD-to-NYU story opens the question of whether new data types ride TEFCA or get their own networks. PACS unregulated, files enormous, 30 competing standards, proprietary vendor incentives. The Dutch precedent with XDS-I and TWIIN shows it can be done, and there are real reasons clinicians want pixels not just reports. * Authentication vs. Authorization (21:31 – 27:39): Pryce walks through how IAS jams identity proofing and data-release consent on rails not designed for the distinction. Epic alone runs the FHIR redirect flow, every other QHIN hands back the treatment CDA with an IAS header, and the antitrust litigation against Epic now treats that architectural choice as an exhibit. * The HIPAA Liability Math (27:39 – 30:37): Why Cleveland Clinic’s general counsel sees only downside without OIG safe harbor. The CMS Health Tech Ecosystem is pushing authentication out anyway, leaving authorization as the more interesting question, including what hospital-side authorization could have unlocked for proxy and caretaker scenarios. * The GDPR Cookie Banner Problem (30:37 – 33:44): Brad’s prediction that patients will accept all and dump the whole record into whatever app asked. Trade-offs of authorization on the app, the credential service provider, or the health system, and what gets replaced with legalese and CARIN-style certification when the technological barrier comes down. * Memorial Day Burger Toppings (33:44 – End): San Antonio sausage wraps, Dutch mayonnaise jokes, and a closing reminder that HTD is hiring. Transcript We ran the transcript through an LLM to smooth it out. So it’s a rough approximation of the conversation (and in many cases significantly clearer than our rambling), but notably diverges from the word-by-word blows quite a bit. Brendan Keeler (00:00): All right, we’re back. The Information Exchange. Ryan is unable to make it today. So we got Pryce and Brad and Brendan. and we have a PSA to kick things off. HTD is hiring. So we are looking to hire interoperability associates. if you are interested in EHR integration, health information exchange, data migration, referrals. If like working with point solutions, like working with payers, like working with clearing houses, big tech, small tech, non-tech, law firms, PE. We got it all. If you want to work on data exchange, if you want to use information blocking practically, not use information blocking, but wield the powers of regulation strategy with these fine gentlemen and the broader HTD team, then reach out to us. And with that, with that, we’re going to kick things off and it’s Memorial Day. It’s the government’s day. We all have off, but Brad (00:45): Come hang. Brendan Keeler (00:55): Let’s talk about what the government’s been doing with TEFCA, the Trusted Exchange Framework and Common Agreement. Pryce, where are we at? What’s going on? What are you excited about? About where are you less excited? Pryce (01:03): Yeah. Well, so real quickly, sometimes I feel like we dive into topics and I think we should have just spent 30 seconds explaining what that is for folks who aren’t hearing about the Trusted Exchange Framework and Common Agreement all the time. So this is a segment, maybe we can call it Pryce Transparency. Shout out to Nathan Von Colditz that’s for naming that. So TEFCA, the Trusted Exchange Framework and Common Agreement. So it was written into the Cures Act that the ONC would find a coordinating entity to manage this nationwide federated exchange framework for clinical data. The way that it was built and sort of the framework itself is that there are various QHINs, Qualified Health Information Networks, like Kno2 and SureScripts, and then Epic built their own called Nexus, and then Oracle’s got one now, and MedAllies has one, and KONZA has one, apologies for any that I’m leaving out. But these Qualified Health Information Networks have sort of very... like bold obligations to the network. And they’re almost like the Verizon and the AT&T and the Sprint of this nationwide network. And when I say it’s federated, what I mean is the data is everywhere, right? So data is in electronic health records, data is in payer systems. And we’re not pumping it all into one big server that sits in a mountain in Colorado or something like that. These are federated databases and TEFCA and the QHINs, these, you know, maybe eight now health information networks allow us to onboard to them to query for Brendan Keeler’s data. Maybe Brendan has an appointment tomorrow and an EHR can say, I want to know more about Brendan before he comes in. Or maybe Brendan himself is saying, it’s my data and I want it now like JG Wentworth. And he goes to do what’s called an IAS, Individual Access Services query to the network. tons and tons of nodes that are helping you on ramp into this network of QHins. So think of it more like a phone book or a spider web than a big database. But TEFCA has been around for years now. It’s been live for years now. Adoption is, I would say lukewarm. It’s like not, it’s not mandatory for any reason, right, Brendan? There’s no, it’s completely voluntary to join. There’s no. incentive structure that’s bringing entities except for added usability for their users, right? Brendan Keeler (03:19): Well, there was the TEFCA exception within information blocking, is an interesting route for the last administration to push it forward. With HTI-5 proposed rules it looks like that will be ripped out. I want to push on what you’re saying. What is your measure for lukewarm? Pryce (03:36): That’s a good question. Good question. Brad (03:38): More than 500 million records. Pryce (03:41): I would say... If you’re familiar with Carequality or Commonwell or eHealth Exchange, which have been the nationwide networks that are around longer, those are still being used to exchange CDA documents, clinical document architecture standard documents, which were genera

  5. 18 May

    The Information Exchange: Lumon on Steroids

    Make sure to follow and listen to The Information Exchange on the podcast app of your choice! For instance, you can find the Spotify version here. The stars have aligned. The crew is back, full strength and four-deep, with (somehow) no one traveling, sick, or on a plane. We covered some choice material pondering the nature of not just Epic, but systems of record, antitrust, information blocking, and competition writ large. Some highlights: * Judy did Freakonomics and Katie Couric (after Acquired and Forbes in the past year). We dig into why a company that spent 40 years letting the work speak for itself is suddenly hiring marketing people and putting its 82-year-old founder in front of podcast mics. * API counts don’t measure openness. Why athenahealth’s developer experience runs circles around Epic’s, and why information blocking changes the co-opetition math for every system of record vendor. * Epic Cinematic Litigative Universe mini-tour: Particle sits waiting for a potential motion for summary judgment in a May of rapid litigative developments. Plus the SSNIP test and why antitrust law is structurally a bad fit for systems of record. * CMS announced electronic prior auth as a new pledge category. The pledging networks (b.well, CommonWell, eHealth Exchange, Kno2) are all clinical data networks. Were clearinghouses snubbed? Why CMS just tipped the X12/FHIR scales with seven months left on CMS-0057. Also: a fashion heat check from our local New York correspondent, Patagonia as Epic’s spirit animal, and the case for Judy on Joe Rogan Relevant Articles * How Leeds avoided relegation: We’re happy for Brad. MOT. * Judy Gets Her Freakonomics On: Discussion of the Freakonomics interview and the insights it brings into Epic * Katie’s one-on-one with Judy Faulkner of Epic Systems: A longer interview by the famous journalist that pushed on Judy a bit harder * Organic Beer by Patagonia Provisions: I can’t believe this exists. Please comment on quality if you’ve tried. * Epic Opens the Door Wider for Developers: A post from last September about Epic’s incremental progress in changing how they treat developers * The Prodigal EHR: A previous article about how athenahealth leads the pack in terms of developer experience * The Iceberg Fallacy: Some further discussion of the cool developer experience and features athenahealth is releasing beyond the basics * AADJ v. Epic: Antitrust case referenced briefly in the episode. Epic’s motion to dismiss was filed on Friday, as mentioned. * 2025 EHR KLAS Report: Fierce Healthcare’s summary of the annual EHR research, which mentions how many Oracle Health customers want to switch but can’t. Mentioned in the article in reference to the SSNIP test. * Epic Litigative Universe: Prior article explaining all the lawsuits against Epic. * Electronic Prior Authorization in CMS Health Tech Ecosystem: Announcement of the new category and early adopters * CMS-0062: An Intra-Agency Cold War Goes Hot: Previous discussion of how prior authorization sits in the middle of the Venn diagram between administrative and clinical Chapters * Intro and Travel Catch-Up (0:00 – 0:44): The crew reunites after time apart and trades notes from Palm Springs, the NBA playoffs, and a trip across the pond. * Judy’s Media Tour (0:44 – 5:16): Judy Faulkner’s recent Freakonomics and Katie Couric interviews mark a sharp break from Epic’s historical posture of silence, raising questions about what’s driving the shift. * Epic Projects Outward (5:16 – 7:20): Why a company that long relied on word-of-mouth is suddenly investing in external messaging, and who inside (or outside) the company might be pushing it. * APIs, Co-opetition, and Athena (7:20 – 12:13): Counting APIs is the wrong measure of openness. A look at what real developer-friendliness looks like and why information blocking changes the economic calculus for system-of-record vendors. * Defense or Real Change? (12:13 – 16:27): Are Epic’s recent openness efforts durable, or a defensive crouch that ends if the lawsuits do? The crew debates how much of the company’s posture toward outside developers is cultural versus strategic. * Boomerangs and the Chief Meme Officer (16:27 – 18:16): Predictions on where Epic’s external-facing energy goes from here, plus a modest proposal for a certain alumnus to make a triumphant return. * The Epic Cinematic Litigative Universe (18:16 – 23:11): A tour of the active litigation against Epic, with attention to why antitrust law is poorly suited to systems of record and where information blocking gives plaintiffs more to work with. * The New Prior Auth Pledge Category (23:12 – 27:22): CMS adds electronic prior authorization to the Health Tech Ecosystem pledge structure, with conspicuous decisions about who’s invited and who’s left out. * Administrative vs. Clinical Rails (27:22 – 29:12): Prior auth has always lived at the intersection of two standards worlds, and the new pledge structure tips the scales toward one. The implications, with the CMS-0057 deadline approaching fast. * The Clipboard Is Still Breathing (29:12 – 31:50): A reality check on whether any of this regulatory motion is reaching actual patients yet, and a debate over how to measure progress when the deliverables are rules rather than experiences. Transcript We ran the transcript through an LLM to smooth it out. So it’s a rough approximation of the conversation (and in many cases significantly clearer than our rambling), but notably diverges from the word-by-word blows quite a bit. Pryce (00:00): All right. Welcome back everyone to this not-a-podcast that we call The Information Exchange. We four are glad to be back together. It’s been a long time since we’ve all been in town. We had travel to Palm Springs, which was really rough. Brad and I, Brendan and I had to, you know, suck it up and go enjoy Southern California. And I’ve been busy with, you know, this like, it’s really hard to watch all the Spurs games because hopefully by the time we release this, they’ll be in the Western Conference finals. So, and Brad, with your football team behind you, was in England for a little while checking out the EPL. Brad (00:33): For all of our big audience in Leeds. They’re very excited to see this. Pryce (00:37): Yeah, exactly. Shout out. Shout out to Leeds United. Well, Brad, why don’t you get us kicked off? What’s first on our agenda today? Brad (00:44): Well, you know, I was in England, so I missed some things and I came back to it’s been a flurry of lawsuits at the beginning of the year as Brendan has hopefully covered. Seems like Epic is active in the courts and now they’re active in our newsrooms. We got podcasts, Freakonomics with Judy and then Katie Couric, a former coworker of mine. If you want to hear that story. Yahoo and AOL merged. We don’t need to go into that section of my life. But I did ride the elevator with her one time, and she was very lovely. Yeah, Judy’s out there at the young age of, am I right in saying 79? Does anybody know for certain? Ryan Tucker (01:18): I think they said 82 on the interview. Brad (01:20): 82, oh man. Well, one thing I’ll say is she was at HIMSS in a leather jacket and she looked sick. So 82 looks good on Judy. And she’s not slowing down. Maybe President is next. Brendan Keeler (01:33): Are leather jackets, I’m not trendy as evidenced with Waldo here, are leather jackets in? Is that a trendy look? Brad (01:38): Well, though, yeah. Pryce (01:44): I think if you’re rich enough... Brad (01:45): Did leather jackets ever go out? It’s just that you have to have the vibe. Yeah. Pryce (01:49): Meaner, yeah. Brendan Keeler (01:50): New York Man is the trendy one of the four of us. We’ll take that word. Ryan, what do you think? Did you see any of those interviews? Ryan Tucker (01:57): Yeah, I watched the Katie Couric one. You know, the whole time we were at Epic, very reserved in terms of anything external facing. Judy did meet with folks internally quite a bit and would regularly talk at our monthly staff meetings. And so we heard from her a lot, but there was never really anything publicly facing. Now that all these lawsuits have started happening, maybe some perceptions that were a little brighter have started to turn. It’s interesting that she starts to speak up. Maybe that’s the more cynical side of me talking there. She, in my opinion, does not have the best media training. I think the lack of like the past 30 or 40 years of doing any public-facing interviews is quite evident. Katie Couric was like very amicable to start. She was even trying to draw some lines between like her path and like the difficulty of being a woman in an industry where it’s really surrounded by men and how they’ve kind of both succeeded. And so she was trying to like maybe find some camaraderie there that felt pretty flat. And then my favorite portion of the interview was she started to talk about like Epic’s culture and it was a true like s**t sandwich tactic by Katie Couric where she talked very highly of the campus, of the art around the campus. And then she mixed in, it seems to be a bit like Lumon on steroids, which if you all have watched Severance is like not at all a compliment, but I don’t think Judy got the reference at all. Brendan Keeler (03:35): Just blew right by it and there were laughs and I was like wait a minute. And I think that’s something worth noting. Freakonomics was kind of a puff piece, was really positive. Katie Couric one, definitely she dug in, but like with that zinger but also some questions. Ryan Tucker (03:53): Yeah, I do wish she followed up a little bit more, like held her a little more to the fire, but also she’s at the Epic conference. I wouldn’t be able to do that personally. There’s also like definitely some analogy to be drawn there about Lumon internally, the Innies versus the outside world. You might se

  6. 22 Apr

    The Information Exchange: Russian Dolls and Headless Tractors

    The Information Exchange does not sleep¹, because, well, CMS is absolutely dialed in lately: * Brad recaps the CMS Aligned Networks launch event in DC: CLEAR, ID.me, TEFCA rails, and Humana’s senior care demo all got stage time, but the question is what happens on the non-patient-access tracks before July * ACCESS approved its first cohort. Brendan plays optimist on CMMI’s willingness to swing big on outcome-aligned chronic care payments while Brad plays pessimist on lemon-dropping and the 50% withhold that could empty out year two. A Polymarket line gets opened at 60%. * CMS-0062 was supposed to be a tidy little drug rule. It is not. We walk through why it’s bigger than 0053, layers onto the 2024 prior auth rule, and in some places contradicts the claims attachments rule from three weeks ago, including the buried RFI to certify payer technology (HTI-2’s ghost returns) * Russian doll payers, Succession-level CMS subplots: why a single payer name hides 15 claims systems, why ERISA keeps TPAs out of reach no matter how well you wire things up, and whether HIIG and the HIPAA standards group are copacetic or knife-fighting over X12 vs. FHIR * John Deere lost its right-to-repair fight. Brad flagged it and Brendan connects it straight to the antitrust and information blocking playbook, diabetes device jailbreaking, and every system of record’s eventual discovery of platform rent extraction * Salesforce went headless. Agentforce opens the UI, APIs, and MCP layer. Brendan argues it’s a per-token pricing play, not altruism. Brad counters with the DoorDash problem and why Epic’s moat is the hospital’s local politics, not the software. Brendan plays foil: in some fraction of the multiverse, this looks as dumb in retrospect as cable companies building streamers. Are you curious about Brad’s Wisconsin farming roots? Wondering about the novel gambling-based business model for the podcast? Or wondering why Missingno is in your inbox? Listen to hear more. ¹ Aside from the two week breaks between episodes Relevant Articles * CMS Health Tech Ecosystem First Wave Event * ACCESS Model Accepted Applicants * CMS-0062: The Entrée Has Arrived * CMS-0062: Same Drug, Two Standards * CMS-0062: An Intra-Agency Cold War Goes Hot * “Have you heard about the Pope?” * The Great Beheading Begins * The Infinite Rare Candies Glitch (Missingno) * The Door Dash Problem * How Interoperability Won on the Farm Chapters * CMS Aligned Networks Takes the Stage (00:00): Brad reports back from Amy Gleason’s DC showcase, where CLEAR, ID.me, and a parade of startups demoed patient identity, TEFCA-powered history pulls, and QR-code check-ins. Payers and EHRs showed up, Humana ran a senior care coordination demo, and the crew reads the tea leaves on how much of the non-patient-access agenda is actually moving ahead of July. * ACCESS Approves Its First Cohort (03:20): CMMI’s outcome-aligned chronic care model (Advancing Chronic Care with Effective Scalable Solutions) lands its first participants. Brendan plays optimist on why ambitious failure is the point; Brad plays pessimist on lemon-dropping and the 50% withhold pushing providers out in year two. A Polymarket line on success gets opened at 60%. * CMS-0062, Not Just a Drug Rule (09:14): The rule that was supposed to be a tidy RTPB cleanup turns out to be bigger than 0053, layering onto the 2024 prior auth rule and contradicting the claims attachments rule from three weeks prior. The gang maps the scope: Medicare Advantage, Medicaid, CHIP, parts of ACA, and why ERISA keeps employer plans out of reach no matter how well the TPAs wire things up. * Payers as Russian Dolls (13:16): Why a single payer name can hide fifteen claims systems and five acquired Medicaid plans, why PBM and plan rails look nothing alike, and why CPT-2 codes keep haunting Brad’s career. Pryce makes the case for shifting regulatory focus from EHRs to the entities actually holding the risk and the purse strings. * Certifying Payer Tech (16:14): : The ghost of HTI-2 returns! An RFI buried in 0062 proposes extending health IT certification to payer technology, a ZombieHTI-2 idea that would turn payer vendors into potential information blocking actors. Brad and Pryce go thumbs up; Brendan predicts a deafening “no way in hell” from payer tech comment letters. * Step Therapy, ADT, and Succession-Level CMS Subplots (22:28): The other RFIs get a quick pass: step therapy portability as the killer payer-to-payer use case, ADT notifications getting another look, and the telling fact that 0062 tells you to use FHIR Da Vinci for prior auth while 0053 just blessed X12 for attachments. HIIG vs. the HIPAA standards group: copacetic swap or internal knife fight? * John Deere and the Right to Repair (23:59): A Wisconsin boy’s late-night text turns into a clean antitrust parallel. Farmers buying forty-year-old tractors to escape dealer lock-in, diabetes devices getting jailbroken, and why every system of record eventually rediscovers platform rent extraction. Brendan lands it on interoperability as the throughline. * Salesforce Goes Headless (And So Will Everyone Else) (26:38): Agentforce opens the UI, APIs, and MCP layer, and Brendan argues this isn’t altruism: per-token agent pricing beats per-seat licensing at scale, and systems of record would rather capture the agent economy than get scraped by computer-use bots. Pryce extends it to EHR nurse-bot licensure and the commoditization of the front end. * Why the Moat Probably Holds (31:14): Brad counters with the DoorDash problem: operational embeddedness is the real moat, and Salesforce opening up mostly makes it harder for four dudes in a garage to dislodge decades of Fortune 500 data. Epic’s value extends past the software into the hospital system’s local politics, ordinances, and employer relationships. * The Cable Companies Building Streamers Risk (33:59): Brendan plays foil: SaaS has maybe four assets (UI, data, schema, business logic), and Salesforce is giving away two to four of them with only a legal agreement standing between them and an upstart. He doesn’t have conviction, but in some fraction of the multiverse this looks as dumb in retrospect as the streaming wars. * Kalshi Bets and Signoff (35:57): Closing odds, a final pitch for the podcast’s gambling-funded future, and the observation that the American economy is now just healthcare and gambling anyway. Transcript We ran the transcript through an LLM to smooth it out. So it’s a rough approximation of the conversation (and in many cases significantly clearer than our rambling), but notably diverges from the word-by-word blows quite a bit. Brendan Keeler (00:00): Ladies and gentlemen, we are back. This episode is going to be CMS-titled, because we’re going to talk a lot about the Centers for Medicare and Medicaid Services. Brad, last week you were boots on the ground in DC. There was an event. What went down? Brad (00:12): Yeah. We missed you all last week because CMS had a big event to celebrate the first launch of applications leveraging CMS Aligned Networks. Amy Gleason brought together a couple hundred people in DC. Much of it was to reiterate the goals of CMS Aligned Networks, introduce some potential new avenues that they could push on, and then allow vendors to show what they were doing with the new rails that CMS is trying to put in place. A ton of it was focused on patient access. That’s something Amy’s been very transparent and consistent about. So we saw CLEAR and ID.me get a lot of screen time, showing patients being able to verify their identity through those solutions and then use the TEFCA rails to pull down their patient history, along with some of the workflows that enables: patients getting faster answers for care questions from AI, checking in and providing a longitudinal patient record at the front desk using a QR code, some scheduling solutions. It really covered the map. Oura did a demo, yes. That was a particularly excellent use case or demo that they showed. One of the things that’s clear is that many of the major payers and EHRs were represented and consistently shown. Pryce (01:22): Wearable technology, you know. Brad (01:38): But there also are a number of startups that are finding quick paths to market access. So overall, some of the things I took away: Amy has been hard at work for the last nine months trying to get people going on these. And while there’s progress, there’s still a long way to go to get this to tie together into a cohesive strategy. Pryce (01:52): Thank you, Amy. Brad (02:01): CMS, just across the board, with the number of things they’re trying to do, has really pushed their technical team to be able to support things like claims data, provider networks, patients pulling all of their medical history. Nobody expects the government to be at the forefront of those things, and I think they’re showing that they can move quickly and they want to. Brendan Keeler (02:22): One question I think is pretty prevalent in the industry, and I certainly have it: we’re seeing a lot of success via the CMS Health Tech Ecosystem for patient access and Kill the Clipboard. That’s where a lot of those demos are focused. What about the other things? You said payers were there. Did they demo? Were they showing participation, or was it more silent wait-and-watch and maybe do stuff as we get closer to the July date? Brad (02:49): Humana had a couple of demos. There was an application for senior care coordination that’s AI-driven. And they showed scheduling through their Medicare providers. It was nice to see some providers trying to expose their networks and enable scheduling. Brendan Keeler (03:06): CMS is kind of firing on all cylinders. They have the event, and the CMS Health Tech Ecosystem continues to rip and do things, but CMS is big and sprawling and multifaceted. Pryce, what else is going on? Pryce (03:20): ACCESS, right? We just heard this week

  7. 4 Apr

    The Information Exchange: The O-PIMP Episode

    We're back after a few weeks off, and we came in hot: * OpenEvidence landed its first B2B deal at Mount Sinai! So we talk about what happens when a PLG darling tries to grow enterprise muscles, the competitive landscape as they do so, and whether the real moat is product or sales. * Then we pivot to MEDVi and the New York Times piece that has everyone talking: can you really vibe code a billion-dollar telehealth business for $20K? (And should you?) * We wrap with some wonkery — the ONC is the ONC again, the O-PIMP is born, and I walk us through why the Henry Schein v. Vyne case might redraw the line on what counts as a health information network in America. And yeah, you’ll have to listen to understand why this exists (and why it goes so hard): Relevant Articles * OpenEvidence Announcements * Mount Sinai to integrate OpenEvidence AI enterprise-wide * OpenEvidence and Tandem Partner to Streamline Evidence-Based Prescribing and Prior Authorizations * OpenEvidence launches Coding Intelligence * Abridge and clinical decision support * OpenEvidence’s Gambits: Some analysis of where OpenEvidence might go after PLG from last summer, including the enterprise motion * From Alert Fatigue to Approval Fatigue: An oldie showing how it was always logical ambient scribes would infuse CDS, another attempt beyond the pop-up * When Horizontal Meets Healthcare: A piece about OpenAI and how their healthcare business model differs and threatens different players * One Copilot to Rule Them All: The copilot convergence, which OpenEvidence is now rapidly joining * Abundance and Agent: A discussion of how AI-powered software development’s marginal costs mean players sprinting to build it all * The PLG Trap: The OpenEvidence v Doximity cases shows how the sword of openness (PLG) cuts both ways, as we discussed on the show * How A.I. Helped One Man (and His Brother) Build a $1.8 Billion Company: The NY Times article on MEDVi * Healthcare at Internet Scale: An article from last summer about the OpenLoop lawsuit that mentions MEDVi * Rik Renard’s MEDVi post * Death to ASTP, Long Live ONC * The Battle for the Soul of HIE (or at Least the Definition) Chapters * OpenEvidence’s Enterprise Pivot (00:00) - OpenEvidence lands its first B2B sale with an enterprise-wide deployment at Mount Sinai, embedded directly into Epic. The crew unpacks the tension between product-led growth and enterprise sales in healthcare (BAAs, PHI access, institutional sign-off) and how this move finally brings OpenEvidence into UpToDate/Wolters Kluwer’s competitive set for real. * The Great Convergence: Scribes, CDS, and RCM Collide (04:28) - Abridge partnering with Availity and UpToDate, back-office co-pilots moving upstream, front-office co-pilots moving downstream. Brad flags clinical trials enrollment as the next obvious adjacency, and the group debates who wins the “wedge into the chart” race. * PLG in Healthcare and the BAA Problem (08:21) - Why product-led growth has historically been almost impossible in healthcare because of PHI and HIPAA. OpenEvidence may be the closest thing to a Figma for healthcare, but the harder, more valuable use cases require enterprise contracts — and that’s a different muscle entirely. * Vibe Coding the Roadmap: OpenEvidence’s Shipping Velocity (13:03) - OpenEvidence is announcing something major every month. The group attributes this to LLM-assisted development and frames it as a wake-up call: if you’re not adopting Claude Code or Codex-type tools, you’re behind. But speed cuts both ways — if anyone can build an LLM wrapper on the same corpus, is velocity a moat or a vulnerability? * MEDVi, OpenLoop, and the GLP-1 Gold Rush (18:40) - A deep dive into MEDVi, a telehealth front-end on OpenLoop’s white-label MSO infrastructure reportedly generating $1.8B in revenue. Brendan connects it to an older lawsuit alleging fraudulent oral tirzepatide marketing. The real question: when website creation, content generation, and national distribution all approach zero marginal cost, harm scales faster than regulation can respond. * AI Doctors and the Guardrail Question (25:51) - If the provider layer also becomes marginal cost — AI doctors on top of white-label infrastructure — the need for guardrails becomes existential. The group draws parallels to Cerebral, opioids, and the recurring pattern of technology outpacing oversight. * ONC Is Back: ASTP Reverts to Its Original Name (28:25) - The ASTP is reverting to the Office of the National Coordinator. The mission doesn’t change, and the pattern is familiar — Democrats expand, Republicans slim down. Pryce mourns the logo, reveals the internal Office of Policy is now the Office of Programs and Implementation (”the O Pimp”), and the group riffs on missed merch opportunities. * What Is an HIE/HIN? Vyne Dental v. Henry Schein One (34:50) - The episode’s deepest policy cut. Henry Schein withdrew from ONC certification, arguably to dodge information blocking. Vyne is trying to use the HIE/HIN actor definition instead — but that definition is famously ambiguous. Brendan breaks down the three exchange topologies and how the ONC preamble’s carve-outs could let nearly every network argue it’s not an HIE/HIN. A Maryland judge’s ruling in 2–3 weeks could reshape actor status for every clearinghouse, ADT network, and API platform in the country. Transcript We ran the transcript through an LLM to smooth it out. So it’s a rough approximation of the conversation (and in many cases significantly clearer than our rambling), but notably diverges from the word-by-word blows quite a bit. Brendan Keeler (00:00) Ladies and gentlemen, we are back. It’s been a bit, a few weeks. We got Pryce, we got Brad, we got Brendan. And we’re here to talk about — let’s start with some of the buzzy stuff. OpenEvidence making moves. Pryce, what are you hearing? Pryce (00:02) We back. Yeah, so diving right in, some of the news coming out of this week was that OpenEvidence has seemingly made its first B2B sale or engagement with Mount Sinai in New York. Apparently they’ll be embedding their application directly into the EHR, which is interesting. Makes sense from a workflow perspective, but interesting for a lot of the things that we’ll talk about shortly and how that allows these products to sort of work in and around each other or compete with each other. And that EHR at Sinai is Epic, if that’s not self-explanatory to anyone. So yeah, OpenEvidence to me is sort of the evolution of UpToDate and the idea that clinicians leverage it to see recent studies, verified research, get help in coming up with a care plan for the patients that they’re treating. And now they’re gonna have this AI tool, which Healthcare IT News is reporting as Mount Sinai’s first enterprise-wide AI deployment across clinical roles. Which was surprising to me considering I think they’re live with Microsoft’s dictation tool. But yeah, first B2B sale for OpenEvidence. It’s interesting, it’s cool. It also means a lot about where the market is headed, where they’re headed, what other companies who might not have had OpenEvidence on their radar will need to do in order to continually compete for physicians’ attention. And for value. Brendan Keeler (01:41) Yeah. Pryce (01:42) What do you all think about that? Brendan Keeler (01:43) What’s interesting is you said they’re competitive with UpToDate. They were doing a similar job to be done — they were providing clinical evidence, they were providing studies — but their go-to-market motion to date until this was totally different, right? They were ad-supported PLG. And so this is a new muscle that actually finally brings them into the competitive set. Pryce (02:06) PLG being product-led growth for those who aren’t like Brendan and Brad, always plugged into the… Brendan Keeler (02:14) You don’t love acronyms? We’re not going to just toss acronyms left and right? CDA, HL7… Pryce (02:18) I mean, well, those I do love because I understand them well. Yeah, so you’re saying OpenEvidence sort of went to market as like, hey, if you’re a physician, you should download this app. It’s free and useful to you, but I’ll make money off of ads. Whereas UpToDate was always — was that Wolters Kluwer? And it was a B2B sale? Is that right? Brendan Keeler (02:42) Yeah, you’re charging a couple hundred bucks a seat, enterprise contracts with a totally different motion that’s just hard, right? Like if you’re used to just saying, hey, pick this up, make it really frictionless for Dr. Smith — or actually you or me, like it’s actually not that hard, as proven by the Doximity lawsuit, for anyone to sign up for OpenEvidence and use it. You can just sign up. You do that and you’re building a very different muscle. What are ads? How do we do ads safely? How do we go to pharma and monetize via pharma? That’s what they’ve historically done. It’s always been a question of, okay, when they get popular enough, how will they lever over into enterprise markets to sell? Do they have the muscle to go to the CIO, CISO, chief medical officer and say, hey, you should rip out UpToDate and put us in? That’s been the question — do they have that sales motion? Brad Thorson (03:31) Yeah. It’s a really nice natural experiment of what is the right sales entry point for these AI-enabled enterprise products, because every time somebody gets a strong enough foothold with a large enough client, they are looking for — okay, yeah, I’m doing your ambient note taking, but now I need to look at, can I do ICD-10 and CPT code generation? It does feel like in the chart, OpenEvidence is competing against Wolters Kluwer / UpToDate, but they’re also competing against the scribes and they’re also competing against HCC coding applications. Do we have evidence of the RCM tools moving up into the chart? And then we have patient engagement and

  8. 16 Mar

    Cat Pits, Reddit Death Threats, and Stipulated Agreements

    Healthcare’s biggest conference has come and gone, so the team is back (down a man or two) to bring you some updates there, as well as every twist and turn of a very busy week in the courts. * HIMSS 2026 felt smaller but more productive…and the sentiment was surprisingly pro-HIMSS over ViVE * AI headlined as expected, but the real conversations were about data normalization and cleanliness underneath the agentic hype * Epic subtly debuted Willow Pharmacy Network, a new “With the Patient at the Heart” product that could signal a long-term play against Surescripts * The American Association for Disability Justice filed antitrust and information blocking claims against Epic over MyChart’s fragmented login experience * A surprise stipulated agreement from GuardDog Telehealth reshapes the Epic v. Health Gorilla case ahead of April’s motion to dismiss hearing * Ryan recaps a guest lecture at Johns Hopkins and the malpractice risk thread that explains more about healthcare’s data reluctance than most people realize Plus we mentioned rumblings of a bonus class action lawsuit, which came true later that afternoon as Fox, Edward v. Epic, Beaudreau, Edgar v. Epic, and Banh, Priscilla v. Epic all kicked off. While on paper it’s not great for Epic, there’s potential upside if they’re able to consolidate effectively. Relevant Articles * Epic's AI announcements: The baseline announcements from Epic at HIMSS which were very AI focused * Introducing Copilot Health: Microsoft’s buzzy announcement of a consumer health product powered by HealthEx, paralleling ChatGPT Health and Claude Health * Epic Beyond the Provider Empire: This article explained Health Grid products and waxed hypothetical about a future pharmacy oriented product, which we saw at HIMSS via Willow Pharmacy Network * Down the Disability Data Rabbit Hole: The strange fruit of minot investigational journalism into a beef tallow influencer’s medical records videos, including one that targeted Epic * Ryan’s post on data quality: Pipes are only half the battle. As access becomes ubiquitous, it’s about what you do with it (if you even can). * AADJ v. Epic: The unexpected lawsuit that launched during HIMSS with disability advocates and patients claiming antitrust, information blocking, and disability violations, which explained Mr Beef Tallow Influencer above * Epic's TEFCA IAS plans: This details their MyChart Central / unified login plans, which seemingly contradict the AADJ claims * Epic v. Health Gorilla: GuardDog Rolls Over: The bombshell of one of the defendants in the Health Gorilla lawsuit turning tail and entering into consent by admitting various violations * Epic Lawsuit-ception: After recording Friday, the lawsuits we alluded to came to light as three separate templated class action lawsuits were filed against Epic for inappropriately disclosing PHI to Health Gorilla. Chapters * HIMSS Recap: Overall Impressions (00:00) - Brendan’s on-the-ground take from HIMSS in Vegas — attendance trends, booth culture, the cat pit, and general sentiment versus ViVE. * AI Announcements: From Chatbots to Agentic (02:48) - Epic’s Art/Penny/Emmy rollout, Microsoft’s patient access chatbot with HealthEx, Agent Factory, and the gap between clean demo environments and messy real-world data. * Data Normalization and the Infrastructure Layer (05:19) - The wave of companies tackling data cleansing, parsing, and augmentation as TEFCA and information blocking rules make data movement easier. * The Under the Radar Announcement of Epic’s Willow Pharmacy Network (06:16) - A new “With the Patient at the Heart” network product targeting specialty pharmacy workflows — and what it signals about Epic’s beachhead strategy into pharmacies and potentially e-prescriptions. * New Lawsuit: Disability Access and MyChart (09:07) - The American Association for Disability Justice files antitrust and information blocking claims against Epic over fragmented portal logins, plus analysis of why the legal claims face uphill battles. * TEFCA, IAS, and Health Tech Ecosystem Updates (16:23) - Kill the Clipboard demos, digital identity with CLEAR and ID.me, and Clover Health joining as the first payer in health information networks (plus the Wall Street Bets subplot). * Ryan’s Week: Teaching FHIR at Johns Hopkins (20:22) - A Q&A with grad students on interoperability trends, wearable data, and the signal-to-noise problem with smartwatch data flowing into clinical workflows. * Malpractice Risk as a Hidden Driver (22:28) - Why the fear of liability shapes provider attitudes toward data volume, RPM, AI summarization, and even HTI-5’s auditability certification debate. * Epic v. Health Gorilla: The GuardDog Settlement (26:35) - A surprise stipulated agreement from co-defendant GuardDog Telehealth changes the dynamics of the case, potentially undermining Health Gorilla’s procedural defenses ahead of the April hearing. Transcript We ran the transcript through an LLM to smooth it out. So it’s a rough approximation of the conversation (and in many cases significantly clearer than our rambling), but notably diverges from the word-by-word blows quite a bit. Ryan Tucker: So we are back with the Information Exchange — two out of the four players here, but we’re going to go strong. I would love to start with a HIMSS recap from you, Brendan. I was pretty busy myself on the other side of the country. Didn’t make it out to HIMSS. Saw some news, but I would love to hear your take. What happened? Brendan Keeler: Yeah, quite a lot. Have you been to HIMSS before? I don’t know if we’ve ever synced on this. Ryan Tucker: Yeah. So I went when I was with Epic, I think about two years in, and I was in the basement doing an Interop Showcase or whatever it was called, where I ran the same script I think 45 times in two days. So that was a very repetitive, not a great experience just in terms of personally needing to do the job there, but it was fun and Vegas was fun. It would be a very different experience now. I’ve been able to go to ViVE since then and things like that, but I haven’t been back since that one showcase. Brendan Keeler: You go to Vegas too many times and you’re in the Venetian over and over again, it just blurs the years. Booth working is different than sort of rogue agent parachuting in and having 12 meetings a day, which is the way that we typically operate when we go to HLTH and ViVE. You can more easily find ROI for certain companies if you’re setting up meetings, going and ad hoc meeting people — versus a booth that really is six figures or above as soon as you have something hanging from the ceiling. Our colleague Brad and I went out, had a ton of great meetings. Overall it felt a little smaller. Since the sale of HIMSS to Informa a couple of years ago, we’ve seen a contraction from 35,000 or whatever it is to 30. And I feel like it may have trended down — the booths were a little more spread out, it felt more spacious in terms of the throughways and stuff like that. There was all the requisite weirdness in terms of people going a little too far with marketing and putting stuff out there. There was one group that had a robot hand on their head that was going like this. That was probably the highlight of weirdness. But it was good. It was very productive. A lot of sentiment was “this is way better than ViVE,” which you don’t expect. They had a cat pit instead of a dog pit. So ViVE typically has all these puppies you can go play with, and they had kittens. I didn’t get a chance to do that, but it seemed pretty cool. They’re trying to be competitive with ViVE in that regard. Are you more of a cat or a dog person? Ryan Tucker: Definitely a dog person, but I would pet a cat. Brendan Keeler: Yeah, kittens are still cute, fluffy — anything to deal with the hangover of being in Vegas. But beyond that, what did we see? AI, all the things, right? Epic, if you look at all the press releases that went through CNBC and Modern Healthcare, it was just all Art and Penny and Emmy for Epic — their AI announcements. We had consumer-facing AI from Microsoft, which is interesting. That’s not particularly their slant versus some of these other companies, but they released in partnership with HealthEx their patient access and chatbot experience. So AI headlined, as you might expect. Ryan Tucker: Yeah. I mean, I think we see that universally all the time at this point, but that’s what I was seeing between meetings, checking on news. Epic, Amazon, Microsoft, Oracle, athenahealth — everyone had “here’s our take on AI.” Epic came out with Agent Factory. So I think we see the shift from general chatbot or LLM AI to agentic AI becoming prevalent. I did put a post on LinkedIn about this. I think there’s a big difference between what you can show at a HIMSS showcase when you have a very clean data environment and a simple workflow to say, “Wow, look at what this can do,” versus AI in the real world — especially with health system data where we know the pipes might be there, interoperability might be working in terms of connecting from place to place, but there’s a lot of bad data out there. The utilization of that data is what’s becoming important. I think especially with agentic use, being able to have a provider just type in something from a prompt and pull up the record that they’re concerned with — we need to have a lot of good data classification, normalization, cleansing of the data that comes in. So I guess I’m wondering, was there any level deeper? Starting on the Care Everywhere team at Epic, we were obsessed with raw number record exchange first. And then it slid toward how we’re actually using the data once it got there. Now with AI, do you see that start to shift — or not yet — where it’s “AI is here, but now how do we actually start to use it”? Brendan Keeler: Totally. Brad and I had maybe four stra

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About

A not-a-podcast video series about health tech's chess moves and the bigger picture for tech as a whole. Brought to you by the HTD Health team healthapiguy.substack.com

Information

  • Creator
    HTD Health
  • Years Active
    2026
  • Episodes
    15
  • Rating
    Explicit
  • Copyright
    © Brendan Keeler
  • Show Website
    The Information Exchange

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