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. Oct 9

    The Information Exchange: Agents Behaving Badly

    We sit on the precipice of conference season (and the holiday season thereafter and probably a proposed rule or two to boot). So we got the gang back together before we hit warp speed to 2027. Brad, Bryan, Pryce and I get into: * The deeply analytical mapping of NFL teams to healthcare data standards * The CDC’s search for a public health data intermediary, and Brendan’s pitch for an agentic network with dumb pipes and smart endpoints * Personal agents like Instinct and Muse, who they actually work for, and whether they make everything more expensive * Utah letting AI prescribe, plus a plan to audit it with secret shoppers Let’s dig in. Relevant Articles * The Immunization Registry Problem: Why state immunization registries remain disconnected and what HTI-2 tried to fix. * Strange Bedfellows by Ina Park (Publishers Weekly): Brad’s book recommendation. * Ask Not What Your Network Can Do: Breakdown of the CDC intermediary RFI and the four possible problems it could be trying to solve. * CDC Data Intermediaries RFI (Federal Register): The source document. Comments are open through November 20, 2026. * Make Networks Dumb Again: The case for agent-native rails with intelligence at the endpoints. * Reducing Administrative Burden with Conversational Interoperability (COIN): A firsthand account of the HL7 Connectathon track. * It covers Josh Mandel’s Banterop reference platform and notes that none of the connectathon agents supported authentication. * Government-Assisted Oligopoly Coordination? A Concrete Case: The Danish cement paper. After Denmark’s antitrust authority published firm-specific concrete prices in 1993, average prices rose 15–20 percent within a year. * Apple and LG, The House For Everyone Else, Agent Standards and Amazon: Ben Thompson’s argument that agents make transparency inevitable. Companies will no longer be able to profit from consumer laziness or ad exposure, so they’ll have to charge for value, which means higher prices. * Cloudflare pay per crawl (Computerworld): The bot tax Brad cites. Cloudflare itself said the model’s true potential may emerge in an agentic world. * Know Your Agent (KYA): Agentic identity and auditability, the backbone of the agent jail concept. * Utah’s new agreements could bring AI to more healthcare processes (KPCW): The expansion news from this week, covering refills, dermatology, and postpartum care. * The Information Exchange: Nuggets and Teasers in DC: Our earlier discussion of the Utah AI doctor pilot and COIN. Chapters * Hometown Teams, Ranked as Standards (0:00 – 3:07): We take on the deeply important question of what the spirit standard for each of our NFL teams. * The CDC Wants an Intermediary (3:07 – 7:14): What is a public health data intermediary, why TEFCA already has a public health purpose, and whether the CDC has forgotten what it learned from COVID. * Make Networks Dumb Again (7:14 – 12:31): Brendan’s tour of existing public health exchange and his pitch for an agentic network. Pryce explains COIN and how interop was conversational twenty years ago. * Agent Jail (12:31 – 18:18): Carequality and TEFCA reimagined as a negotiation between agents with an audit trail. Bryan on whether agents can parse a six megabyte CDA and explain what’s missing from a response. * Friction as a Feature (18:18 – 20:18): Brad argues that token costs might push requesters to ask for less and senders to clean up their data. Seven sulfa allergies are discussed. * Personal Agents Come for the Phone Lines (20:18 – 24:36): Brad’s tour of Instinct, Muse, and dots, including a Copenhagen trip and a prior auth phone call. Brad is called out for using WhatsApp. * Who Does Your Agent Work For? (24:36 – 30:10): Idiocracy, invisible steering, and the risk of payers and pharma influencing personal health agents behind the scenes. * Do Agents Make Everything More Expensive? (30:10 – 34:05): Ben Thompson’s theory that disappearing ad revenue raises prices, the Danish cement problem, and Brad’s prediction that buying moves to channels that died a decade ago. * Utah Lets the AI Prescribe (34:05 – 37:56): Bryan and Pryce on the expanded pilot, from acne imaging to the question of whose license is on the line. * Secret Shoppers and Sign-Off (37:56 – End): A plan for auditing AI clinicians with fake patients, plus our fall conference schedule. 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 (00:01): We’re back in action. We’ve got Pryce. We’ve got Brad. We’ve got Bryan. Fall is here. Football is here. So, your hometown football team: if it was an interoperability standard, what would it be? Pryce Ancona (00:17): The Commanders, unfortunately, were my football team. I picked them over the Ravens, which I really should not have done. I’ll compare them to X12, because for the longest time they sat underneath Dan Snyder, and he used his ownership to leech money from Maryland and Virginia. So yeah, X12. Brendan Keeler (00:39): There you go. Brad, what do you got? Brad Thorson (00:43): Do we have a standard that’s owned by the people? I don’t know if you guys know this, but the Green Bay Packers are the only professional sports team in the US owned by their fans. So I’m thinking: what’s a standard from a rinky-dink, podunk town of sixty thousand people? Brendan Keeler (01:02): Maybe it’s upstate New York. When you’re transferring immunizations there, they have a weird transport standard. I forget what it is, and I don’t know if they’ve changed it, but it’s totally bespoke. Unique, rural-esque area. Brad Thorson (01:17): Or NCPDP. I take the rural healthcare call, that’s a good one. But I was thinking not a whole lot of people specialize in NCPDP. It’s out there, rural, but one of the greatest. Brendan Keeler (01:33): Every EHR and every pharmacy system supports prescriptions. Brad Thorson (01:39): How many people can we find who are just going to drop in, ready to read those docs? It’s specialized. It’s powerful. Brendan Keeler (01:47): You’ve chosen violence against the entire NCPDP community. Pooja’s just going to call in and be like, “What the hell?” Pryce Ancona (01:54): If we’re actually thinking about the Packers being owned by the people and all those different stakeholders, I’m going to go with Da Vinci implementations, because everyone has their own flavor and it’s going to be pretty bad come January. Brad Thorson (02:06): Do not put that on my Green Bay Packers. Get out. Brendan Keeler (02:12): Bryan, what about you? Browns? Bryan Fowler (02:16): It’s a bold comparison, but I’ll go with FHIRcast and Subscriptions. Every year this is going to be our year, we’re going to do great, and maybe this is the year. Big things, bold things, new stuff. Brendan Keeler (02:34): So the Philly Eagles. On top of the world not so long ago, now tremendously flawed, broken, and taking hit after hit. I’ve got to go CDA documents, getting ripped out of many of the HTI-5 criteria. Injury after injury, no longer the darling of anyone’s eye. Brad Thorson (02:55): Jalen’s doing okay. Brendan Keeler (02:57): We’ll see how the rest of the season shapes up. They had their lowest offensive output in twelve years last game. Brad Thorson (03:02): The Packers are IIS. There we go. Brendan Keeler (03:07): Speaking of IIS, the CDC has an RFI about interoperability, asking what intermediaries are necessary, what networks are out there, and what the future should look like. What do we think about the future of public health interoperability? Bryan Fowler (03:30): I like this one. When I first saw it, I was like, what is a data intermediary? But reading it, I think that’s the point of the RFI: what defines a data intermediary, and what feedback do we have on governance or standards for an intermediary that isn’t as specific as an HIE or TEFCA. It’s broader, and it’ll be interesting to see what common vocabulary comes out of it. Brad Thorson (04:04): I was confused by this and haven’t dug in far enough to have a great opinion, but TEFCA theoretically has a public health function. So my first thought was the purpose... Pryce Ancona (04:16): Exchange purpose. Brad Thorson (04:20): Thank you. Didn’t get great sleep last night. The other thing is, when the pandemic started, I was working in diagnostic testing and reporting. There was no standard for states, labs, and providers to report disease state information back, especially at the volume we were doing it. There was an enormous effort by the CDC to create electronic reporting methods, so there should be quite a bit of opinion and infrastructure already established. Also, we have a fifth guest on the podcast today. I apologize, guys. Brendan Keeler (04:57): Have we asked its football team and what standard it is? Brad Thorson (05:01): He’s from Texas. Big Jerry Jones fan. So what would we say there? HL7? Brendan Keeler (05:10): America’s standard. Brad Thorson (05:13): Yeah, everybody loves their HL7 messages. Brendan Keeler (05:15): Good on offense, all-time bad on defense. Brad Thorson (05:18): Back to the CDC. Great, glad we’re asking people for their thoughts. But I don’t know if there’s been such atrophy in the organization that they’ve lost the intel they gained from a Herculean response to COVID, and why we aren’t using other networks. Pryce Ancona (05:36): Not having much experience in public health, my first question is: the CDC doesn’t collect data in any normalized or efficient format today? That’s somewhat surprising, particularly because I know states often have immunization registries and prescription drug monitoring programs. I didn’t realize none of that rolls up to a federal level. The witch hunt HHS is

  2. Sep 18

    The Information Exchange: Cerner Milking Edition

    Apologies to everyone receiving this for a second time today. The post accidentally went out to paid subscribers only, so was forced to republish to ensure all readers could get in on the ATH action. After a short interlude, we’re not only back, we’re trying something new. We’re going Around the Horn (RIP). For those who don’t fancy the sportsball, the now defunct ESPN format is a rapid-fire panel debate where the moderator awards points, docks points, and wields the mute button with (questionable) impartiality. Did we decide on this format minutes before filming? No one knows. We rattle through a great sequence of topics: * Is this a podcast? * Is Oracle Health dead or alive? * Who would buy Cerner if Oracle sold it? * Are we doomed by AI? * Why does the front desk still hand you a clipboard when your chart is sitting one Care Everywhere query away? Along the way we get the unofficial five-phase history of Oracle, a serious argument for IBM as the buyer, a Weapons of Math Destruction detour, and points flying left, right, and every direction in between. Let’s dig in. Relevant Articles * One Verb for Oracle Health: Last week’s read of the earnings call, the agentic ambitions, the missing growth numbers, and the RPO-versus-GDP comparison that gives this episode its title. * An EHR for Headlines, Not Health Systems (Yet): The AI-native rebrand against ambulatory reality, which is Brad’s “when do we actually see it” question. * The $50 Billion EHR Question: The VA reboot behind Brickner’s congressional-hearings-and-bad-press argument. * Oracle falls 5%: $700 million more in layoff costs, and Ellison’s $7.5 billion sale is off: A not-so-great week for Oracle * SaaSmageddon and the Limits of Disruption: Systems of record enduring through AI, which underwrites the Constellation riff and Brad’s hold case. * We Must Pace The Frontier: Dario Amodei’s case for slowing capability gains, built on recursive self-improvement and the OpenAI-Hugging Face agent swarm that Brad brings up. * Stop Panicking About AI: The Matt Stoller piece Brad half-remembered, arguing the doom messaging and the IPO calendar are suspiciously well aligned. * Maximum Overdrive: This is the future the frontier labs envision for us. * Questionnaires and Such: The 2024 answer to Nathan’s question, splitting internal, external, and questionnaire data and explaining why a provider has to reconcile the last two. * CMS’s Health Tech Bombshell: The original read on the pledge, including the QR code and SMART Health Card skepticism Brickner voices. * CMS Health Tech Ecosystem categories: The pledge list we were handed before recording, now twelve categories deep and including Friend of the Ecosystem. * Know Your Medical Bill Of Rights: The No Surprises Act protections Ryan Tucker used on his anesthesia bill, plus the good faith estimate rules for anyone not using insurance. * Much Ado about Diagnostic Images: PACS as the parallel system of record, the backdrop for Ditch the Disk and the Wisconsin CD. * Epic launches new diagnostic image exchange: Care Everywhere Diagnostic Image Exchange over FHIR and DICOMweb, the Epic-to-Epic version Brickner references. Chapters * Intro and Is This a Podcast? (0:00 – 2:50): New format, new rules, and the crew litigates whether a thing on Spotify with four people talking counts as a podcast. Brendan penalizes himself one point before the first question is even scored. * Oracle Health: Dead or Alive? (2:50 – 7:15): Layoffs, earnings, and Larry Ellison’s aborted stock sale. Brickner says spin it off, Tucker says it’s already dead, Brad says Larry is playing a longer game. * The Brendan Keeler History of Oracle (7:15 – 11:44): Five phases from the 1979 database company through horizontal apps, vertical systems of record, hardware, cloud, and now selling data centers to AI buyers. * Wait It Out or Sell It Off (11:44 – 16:42): Brad argues the training data alone justifies holding. Brickner counters that Oracle needs cash, has already pulled every other lever, and is buying congressional hearings it doesn’t need. * Who Would Even Buy Cerner? (16:42 – 23:08): An IPO, Alphabet, and Brad’s FedRAMP-constrained curveball: IBM. Brendan floats the frontier labs and the phrase “Claude on Cerner.” * Constellation Software, But for Oracle (23:08 – 25:20): Why nobody in Big Tech except Microsoft has ever really run a vertical system of record, and why Oracle might just milk this one forever. * Are We Doomed? (25:20 – 32:13): p(Doom), IPO incentives, and whether the slow-down messaging is safety or margin management. Tucker argues we’re doomed in microcosms first, starting with everyone the model wasn’t trained on. * Why Am I Still Filling Out the Clipboard? (32:13 – 39:25): A listener question turns into four theories: the metadata of self-report, the patient who isn’t taking any of their forty medications, purpose of use limits on treatment queries, and the front desk just doing what it always does. * Will Kill the Clipboard Actually Fix It? (39:25 – 44:14): Whether federal policy should be spending its attention on intake forms, and Brickner’s objection to routing data through QR codes when the national networks already move it. * CMS Health Tech Ecosystem Picks (44:14 – 49:36): Diagnostic-quality imaging exchange, pharmacy and drug pricing, and price transparency. One host burns his turn on a joke and has to find a real answer on the clock. * Scores, Sponsor, and Brooklyn (49:36 – End): Nobody knows the score except Brad, who has been tallying the whole time. 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 (00:01): Alright, after a little interlude, we’re back. It’s fall. Fall setting, except for maybe Ryan Tucker in Florida, where it never hits. Ryan Tucker (00:12): Perpetual summer hell. Brendan Keeler (00:14): But football’s back, kids are definitely back in school, and off we go. So, a new format attempt here where we do a little Around the Horn. For those less sports inclined, this comes from ESPN. We’re just going to go around and fire off some questions. I will be the judge, jury, and executioner for the team in terms of awarding points and discretionary muting. So the first question for the team, and let’s start with you, Brad. Is this a podcast? Brad Thorson (01:44): Well, we should go all the way back to the origin of the term podcast, incorporating the iPod. And I know many, many of our listeners still have iPods and are consuming this as a weekly download. So I would say it definitely qualifies as a podcast. Brendan Keeler (02:00): Ryan. Ryan Brickner (02:02): I’ve already started telling people that I made my podcast debut on here two weeks ago. So if it’s not, then I’ve lied, and I do not consider myself a liar. Therefore, podcast. Brad Thorson (02:07): I will say, I think Netflix considers everything a podcast at this point. Brendan Keeler (02:04): I’m going to penalize myself negative one point for that crosstalk. Okay. Nice and brief, to the point. Ryan Tucker. Ryan Tucker (02:34): I mean, for Around the Horn style, I feel like I have to do a contrarian take. But if it’s not a podcast, what the hell is it? Yeah, podcast. Brad Thorson (02:44): A webinar. Brendan Keeler (02:44): Some out there have called it a webinar. I would strongly push back. We are literally on Spotify, we’re on iTunes, and we’re going to lean into this now. We are a podcast. We’re going to own our birthright. We’re the wayward son returned. So I’m going to give Ryan Tucker two points, that was the briefest. Brickner, one point. Sorry, Brad, zero points. A little too wordy. No one wants to hear the history. Alright, next question. Oracle Health. Dead or alive? Where are we headed? A lot of stuff has happened this week. We saw another round of big layoffs across Oracle and Oracle Health, reported through Reddit and also some of the major publications. We saw their quarterly earnings, and those earnings were great. They are like the 26th largest country in the world by RPO, by remaining performance obligations, compared to GDP. However, that need for data center spend has pushed them to prioritize that over other business facets like employees. And then lastly, Larry Ellison trying to sell off much of his stock and then, with major pushback, recanting from that plan. Not a great look. So maybe I’m leading the witness with some of the things that have happened, but who wants to go first on Oracle Health takes? Ryan Brickner (04:14): Yeah, I’ll take this one. You mentioned that Larry Ellison is selling off some stock. The one thing I’m shocked I’ve not heard so far is Oracle putting Oracle Health up for sale. They need the cash for their AI data centers, they need it for their other operations, and Oracle Health generally, in my mind, does not fit what the company wants to focus on. So I’m not calling it dead or alive, but what I do think is that Oracle is getting to the point where they have to be considering spinning it off, getting some cash for that, and letting somebody else take on the operational burden that is building a functional EHR. Brendan Keeler (04:55): Alright. Confident take. Ryan Tucker, you got anything? Ryan Tucker (04:59): In Around the Horn style, I’m going to argue a little with Brick here. I don’t disagree that they might need the cash for their other efforts, but who’s going to buy it? It’s dead. It’s dead. Don’t touch it anymore. They’re spending more money on severance and data centers than they can put into Oracle Health. Dead, done. Brendan Keeler (05:21): Brad, tiebreaker here. Brad Thorson (05:22): We’ve heard a lot about the AI-first EHR. I don’t think anybody sees the move coming whe

  3. Aug 25

    The Information Exchange: Epic Dúnadan Edition

    UGM week has come and gone, so we’re recording closer together than usual. Epic spent a week announcing things in front of 11,000 people and the group chat would not settle down. The absolute legend that is Ryan Brickner joins for the first time. He’s the freshest out of Epic of anyone here, which makes him useful for checking our takes against what the building actually thinks. We get into: * Epic Rangers and whether that’s Texas coded, power in nature or a Tolkien callback. * Ergo as an orchestration layer sitting directly on top of EHI, and what that implies for third party access. * Epic’s continued assault on third parties, with post-discharge calls, Autonomous coding, payments, and eFax * Going down market via Sonnet, Garden Plot, and Orchard * Leadership thoughts with a brief read on who was on the UGM stage. And yes, for those tracking, we’re absolutely counting the prediction from a few episodes ago about federal action before end of summer as true (sorta) as various news outlets announced that the FTC has been looking at Verona. Let’s dig in. Relevant Articles * UGM Hot Takes 2026: General purpose article about the announcements and pronouncements out of Verona this year * Epic in the Crosshairs: Earlier signals that the FTC and others were looking at Epic in February * Is Epic’s Garden Plot a Failure?: Prior art on historic Epic’s downmarket strategies and their relative successes * The Lesson of Gates: Extrapolating out from the brief Microsoft court case mention * The Epic Abdication: Relevant to the discussion of Seth Howard and other leaders Chapters * Epic Rangers, or Possibly Power Rangers (0:00 – 3:54): A program announced early enough in the week to dominate the chatter and late enough in the planning that TLs were told not to discuss it. Epic staff sign long term contracts with customers, leave Verona, and become ultra analysts. * Forward Deployed, and the 320,000 Flex (3:54 – 4:46): Rangers as Epic’s answer to Palantir, complete with a snarky tweet. Plus why 320,000 annual applications says more about the marginal cost of applying than about Epic. * Ergo and the Great Test of Our Time (4:46 – 6:56): Ergo as an orchestration layer over Art, Emmie, Penny, and UpToDate, sitting directly on top of EHI. If Epic’s bundled solutions get API access to that data, information blocking says third parties should too. * Emmie Calls You Back (6:56 – 7:58): Automated post-discharge outreach as a fix for the readmission problem, and what it frees up for the patients who need a human. * Boxing Out the On-Ramps (7:58 – 9:15): Payments, autonomous coding, eFax, and AI care navigation. Epic moving into categories currently owned by Inovalon, R1, and a long list of point solutions. * The FTC Question Nobody Was Going to Answer (9:15 – 10:47): Why anyone expected active investigation talk on stage is unclear. The antitrust paradox for systems of record and whether the market can be gerrymandered over the hump. * Sonnet, Garden Plot, Orchard (10:47 – 14:01): Three down-market offerings where one or two would do. Sonnet has been tried since 2010 and apparently ripped out a few years ago. Orchard, pre-wired and single tenant, is the one with real appetite behind it. * Cool Things Ahead and the Succession Read (14:01 – End): Seth Howard hosting the segment in Sumit’s absence. How much to index on that, where he sat in the big four, and whether the it factor is teachable. 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. Here we are. It’s UGM Week, special episode. We don’t usually get together this frequently. We have a new guest, Ryan Brickner, here for the first time to provide his perspective on Epic along with the rest of us. So let’s dive in. Who has a thought or a hot take? Pryce Ancona (00:17): Gosh. A lot happened. A lot of chatter is to be expected and you have to sift through the chatter to determine what’s actually exciting and what you didn’t know about. Let’s talk about Epic Rangers first. That was one of the first things I heard about, and it’s always intriguing to me as someone who left Wisconsin to move to Texas and thinks about how I used to work for Epic. I’m always astonished at how they tweak rules to allow folks to either stay on or not stay on. It’s obviously very purposeful. We’ve seen hypotheses around the strategies with Epic Rangers, but does anybody want to explain the program? Brendan Keeler (00:57): It’s really evocative of Power Rangers for me. Maybe in Texas it’s different, like Texas Walker Ranger, but I’m thinking Power Rangers and I’m like, I’m a twenty two year old at Epic, yeah, I’ll be a Ranger. Pryce Ancona (01:09): I wanna be a Ranger. I’m actually getting more of the Aragorn kind of vibe. Like this is perhaps someone from Epic that has fallen from grace, and though they were once the Dúnadan they are now just a lonely ranger, waiting for hobbits at the Prancing Pony Inn. Brad Thorson (01:28): Somebody insert a Sauron joke here, please. Brendan Keeler (01:32): You would think that they did a lot of thinking about the name given all these connotations. Like, wow, how cool. And no, the boots on the ground is they came up with it on like Sunday and they haven’t actually fleshed it out. They’re telling the TLs, the team leads, and the BFFs, “Don’t talk about it yet. We’re not ready.” So what is it? What was announced, Pryce? Pryce Ancona (01:52): The idea is that Epic employees who are interested in leaving Madison, and that’s a big deal because you have to work in Verona right outside of Madison if you want to work for Epic, those who want to leave could potentially sign long term contracts with Epic customers to continue supporting them. Question mark: as an Epic employee? Getting paid by the health system? Sort of hard to determine. But I’ve seen whispers in the Ex-Epic Slack channel. Brendan, maybe this is a way to allow Epic staff to go elsewhere, move back to where they’re from, and then leverage all these AI tools that are gonna help create configurations and do system setup for Epic clients, to be ultra analysts, if you will. They’re gonna have the power of multiple analysts by being plugged into Epic and aware of internal happenings, but full time for a particular customer. Maybe they are Power Rangers. A quirky little announcement in the midst of all the actual product announcements they made. Brendan Keeler (02:57): Brickner, you were the freshest from Epic. Would the Ranger opportunity have retained you? Ryan Brickner (03:04): I don’t know if they could have found a good enough position to retain me any longer, but I definitely think it’s a very exciting opportunity. I think it’s really interesting how it plays with their overall AI strategy, because it seems like the underpinning of the program is basically that all the grunt work analysts do right now is going to get automated away. So these analysts are gonna become much more strategy oriented, much more big picture oriented. And Epic is saying, “Hey, since this is gonna become more of a specialized role, here’s some more specialized folks that we’ve trained and that we trust on our side to do this kind of big picture thinking. Go and upgrade your health system even further.” So not for me, but I think it’s an awesome direction to see them going. Brendan Keeler (03:54): Yeah, and maybe this assuages some of the non-compete stuff. Not really, but at least there’s more opportunities for people. Certainly they upped their beef with Palantir. This is their forward deployed engineer, and they even did a snarky tweet about it. So we shall see. They also said, “we have 320,000 apply annually for jobs at Epic,” as if it’s a flex. I don’t think it’s a flex. AI has meant that the marginal cost of applying to a job is almost zero, so every company is flooded by crap applicants. It’s not like they have 320,000 tremendous applicants. They have bots that are firing off twenty applications at a go, coming out of Madison, UW or Notre Dame or wherever. What else do we find interesting? Brad Thorson (04:46): The Ergo announcement, obviously Judy spent a ton of time there. Ergo, what I read about it, is an orchestration layer on top of a bunch of different existing products and potentially workflows that you could build yourself. My big question coming out of it, as the only person here who hasn’t worked at Epic and hasn’t been part of a UGM, is that they’re going very much “we’re gonna control every aspect of our customers’ workflow.” But Ergo sits directly on top of EHI. So the big question for me is, does this mean everything you can do in Ergo has to be made available to third parties because of the information blocking laws? And potentially EHRs that try to become particularly insular actually erode their advantage of working with their customers on non-EHI centric workflows. Maybe there’s a place for headless EHRs in our future. Anybody excited by the words I said? Brendan Keeler (05:47): I have thoughts, but Pryce, you’re smiling. Pryce Ancona (05:50): No, no, I wanna hear you. Brendan Keeler (05:51): You mix together the Agent Factory stuff, which is their “build with agents,” that people are super excited about. I’m not as much. No-code builders have a long and torrid history of underperforming. But AI could fix them, maybe. The Ergo stuff, I think you’re right. It is a rebrand of some Art stuff and other AI things they’ve been doing, as well as the UpToDate partnership for clinical intelligence that’s in there. So it’s a rebrand, to your point. And it does beg the question: if API access to EHI is enabled for the internal bundled solutions of A

  4. Aug 14

    The Information Exchange: Standards-based Thruple Edition

    All the kids went back to school this week, which means so did we! Fall is the busy season in this industry, with a long syllabus already lined up. * Brad went to DC for the one year anniversary of the CMS Health Tech Ecosystem and came back with a read on where it stands. * CMS-0057 goes live Jan 1! Pryce (who has spent a lot of time in the prior auth weeds lately) is nervous. The million subsystems in a trench coat that are payers has many groups in a spec-off. We also cover the fall reading list (HTI-5 this month, HTI-6’s ambiguous fall launch, and more), why enrollment is the unsolved problem that keeps apps off FHIR, and Brad’s mid-pod theory about blood pressure cuffs shipping with cellular radios and a TEFCA connection. All that and more in a fun one. Let’s dig in. Relevant Articles * CMS’s Health Tech Bombshell: The original read on the Health Tech Ecosystem pledge, now one year old and the subject of Brad’s DC recap. * Artificial Scarcity, Meet Artificial Intelligence: Prior art about MCG and Interqual * The Regulatory Roadmap Reappears: The Unified Agenda drop we mention * HTI-5: When the Scorpion Learns to Swim: The deregulatory rule finalizing this month, including the information blocking provisions EHRs aren’t psyched about. * A Shot Across the ONC’s Bow: Will the EHRs clap back about HTI-5 information blocking provisions? We think yes. * An Argonaut Miss?: Title doesn’t state it well, but ONC needs to think broader than just the Argonaut Subscriptions IG. Solve the enrollment problem or you’ll have another five years of apps complaining. * CMS Launches ACCESS: Had to dig for this one, but this is background for Brad’s on-the-fly theory about devices, GLP-1 monitoring, and where the payment models point. Chapters * Intro (0:00 – 0:47): We’re back and so is the school year, regulation, and a splash of litigation. * A Year of the Health Tech Ecosystem (0:47 – 5:19): Brad’s DC report of the CMS Health Tech Ecosystem anniversary event. * Four Months to January First (5:19 – 11:13): We go deep on CMS-0057, including the hidden complexities that are causing so many organizations pain. * The Light DTR Casualty (11:13 – 13:52): HTI-4, buried in the inpatient rule, killed the SMART app path and yoked prior auth to the EHR. * Could 0057 Have Been Better? (13:52 – 17:52): Pryce weighs in on whether there was a better path for the prior authorization roll-out. * The Enrollment Problem (17:52 – 21:18): The fall reading list, including why Argonaut’s patient subscription still leaves 99% of apps unable to be FHIR native. * Blood Pressure Cuffs with Cellular (21:18 – 23:20): Brad’s mid-pod theory on BALANCE, TEMPO, ACCESS, ELEVATE, and devices getting roped into certified health IT. * FMK: Subscriptions, Bulk FHIR, Agents (23:20 – End): We go around the horn to determine the fate and future of American interoperability with some hard decisions. 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 may diverge from the word-by-word blows quite a bit. Brendan Keeler (00:00): All right. In the words of Billy Madison, back to school, back to school, to show the listeners we are not fools. It’s school time. Ryan, your kids are going to kindergarten? Ryan Tucker (00:11): Pre-K two, pre-K three. Very serious stuff. Brendan Keeler (00:13): Pryce, your kids pretty soon. You have a broader array of ages. Pryce Ancona (00:18): They started yesterday. We’ve got a third grader, a first grader, and then a two year old at the pool right now just rocking the goggles. He’s chillin’. Brendan Keeler (00:28): Well, more broadly, we’re all getting some homework, because we’re headed into a busy season of regulation, of federal litigation perhaps, of lots of stuff coming to close out the year as we head toward the deadlines. The test comes January first for many payers. But before we get into all this, Brad, you went to DC to meet the teachers, did you not? Brad Thorson (00:47): I did. We had the one year anniversary for the CMS Health Tech Ecosystem. This is the fourth event they’ve held in Washington so far, fourth or fifth. A couple things really stick out. One of them is that Amy Gleason has hit her stride. She’s not in this to be Usain Bolt. She’s going to be the marathon runner who breaks the world record. They’ve now got over forty people working in product, they’ve continued to expand the number of categories they want entities to participate in, and one of the most noticeable things at this event versus the others is that the big legacy players showed up in force and they are pledging to more categories than they maybe initially wanted to. That’s a good sign that the industry is adopting the idea that coopetition is positive. One of the really big takeaways for me is that there are polarizing figures in this administration, and Chris Klomp was absolutely perfect in articulating the vision of the health tech ecosystem. He identified that this has nothing to do with politics and is really about returning control to patients. I thought he was the best speaker by far at the entire event. It’s awesome that he’s moving into higher positions of power, because I’d watch that guy talk about health tech all day long. No offense to anybody else who speaks about it. I just think he’s fantastic. We’re seeing all of the major EHRs show up and figure out how they want to participate. We’re seeing some of the newer kids on the block, who maybe didn’t have as big of a health tech footprint beforehand, getting deprioritized or seen as necessary but not sufficient actors in the space. That first category of tools depended on patient identity, so CLEAR and ID.me were omnipresent, but we saw a lot more of your Epic, your MEDITECH, and so on. And we got payers. Most of the major payers were present, which was again very cool to see. I’ve got to give a shout out to b.well for committing to every single category, just so that Liz Lewis can’t sleep at night and has to run every work group. It has come a super long way. We’re seeing a lot of maturity. The big question is going to be breadth versus depth and whether they can do both. Amy seems confident they can, and the next year will really be about which of these categories stick and which ones they continue to invest in. Brendan Keeler (03:16): It’s such a dichotomy across the board. Tremendous successes and things that aren’t real, all mixed together. You have them threatening regulation on one hand, like you’d better go do this voluntarily or we’re going to make you do it three times over. And then you have Oz on stage asking why aren’t you more like Uber, why aren’t you going and breaking laws. There are all these fun ironies, but they’re getting s**t done. They’re going to put some of these capabilities in HTI-6 to make it happen. Industry has proven out many of them, so then they get to say, okay, this gets the pilots out there, and now we’re going to get everyone to do it. It seems very logical that that’s what we’ll see. That’s what struck me watching the recording, the bipolar nature of it. Brad Thorson (04:07): The other thing I felt seeing big names present in that room takes us way back. I started a health tech company almost a decade ago and I knew basically zero about healthcare. It was really, really hard for me to find people who would teach me how things actually worked, so it was a process of trial and error. An undernoted and very cool thing about the Health Tech Ecosystem is that if you’re willing to participate, no matter the size of your entity, you can be on calls with executives from Epic or MEDITECH and understand their workflows and requirements. I don’t know that we’re going to be able to measure this, but if we could, I think we’ll see an acceleration of startups understanding traditional healthcare workflows for things like prior authorization. Their previous approach may have been, I’m just going to screen scrape everything and break the system. Now they understand why the system works the way it does and can start to operate inside of it. Brendan Keeler (05:10): So the teachers made a good curriculum for us. Is that what I’m hearing? Brad Thorson (05:14): Yeah. We’re going back to school and we’ve got a great syllabus. Brendan Keeler (05:19): One of those pieces of the curriculum is prior authorization. We already have the CMS-0057 deadline on January first. There’s 0062 hanging out as a proposed rule, and now the CMS Health Tech Ecosystem has a prior authorization work group. Pryce, you’ve probably been the deepest of anyone on the team working with payers and delegated vendors on prior auth. How are we going to do? Pryce Ancona (05:44): I’m nervous. Everyone working in the 0057 space right now is feeling like holy cow, I can’t believe folks are going to try to start using this in production on January first. It is an administrative workflow, so it’s not a patient safety escalation to me. I’m not going to start shouting from the rooftop that everyone needs to protest outside the Humphrey Building and get 0057 pushed back a year. The biggest thing I think people don’t realize is that we act like the prior authorization problem is health systems needing to speak with payers. Right now it’s a very administratively burdensome process, and it’s a terrible time in the life of the patient. If they’re getting permission from their insurance company to do something from a medical perspective, they might be sick or anxious to figure out why they’re sick, and it takes too long. But we simplify it to the EHR should be talking to the payer systems. Three easy steps, and doctors love these three easy steps: you figure out if you need prior auth, you figure out what information you should be pr

  5. Jul 13

    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

  6. Jul 4

    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

  7. Jun 9

    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

  8. May 26

    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

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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
    19
  • Rating
    Explicit
  • Copyright
    © Brendan Keeler
  • Show Website
    The Information Exchange

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