Guests: Bill Lakenan & Benji Graham – FHIR evangelists & innovators at Bellese

Where We’re At

* CQL maturity: Finally stable enough to calculate without different engines giving different answers. But DEQM (Data Exchange for Quality Measurement) is still a labyrinth powerful, but too flexible and waiting for industry alignment.

* QI Core vs reality: Full QI Core adoption is a fantasy today. The pragmatic move is USCDI+ Quality subsets stop boiling the ocean, start with buckets.

* NCQA & CMS pressure: Both are turning the screws. NCQA’s push for FHIR-only HEDIS reporting and CMS’s signals on hospital quality programs mean “claims-only” days are numbered.

The Payer/Provider Dilemma

Legacy organizations face two doors:

* Stand up a FHIR-native system

* Slap a FHIR façade on legacy infrastructure

The advice: don’t wait. Off-the-shelf solutions exist, but the hurdle is domain expertise and data quality. Bad data = garbage measures. As Gene put it, we’re “building a new house while still living in the old one” but you still have to start building.

Holy Grail Moments Ahead

Two tipping points will define the dQM journey:

* When digital quality becomes cheaper and easier than today’s bloated admin burden.

* When FHIR measures double as care gap alerts in real time. Imagine a doctor getting an instant ping “you’re overdue for a colonoscopy” instead of an end-of-year spreadsheet.

And let’s not forget the patient. Today’s care gap lists never reach them. The new paradigm? Agents, APIs, and FHIR empowering patients to close their own gaps.

FHIR + AI = Frenemies or Besties?

* Bill’s take: AI won’t kill standards it’ll sharpen them. Use LLMs to craft better, transparent measures.

* Benji’s take: AI + FHIR are a perfect match. FHIR’s granular, graph-like structure is exactly what agents and LLMs love. The future is FHIR-fueled AI workflows, not black-box medicine.

Industry Spice

* TEFCA & endpoint discovery: The dream is making FHIR directories “as trivial as Google Maps.” Until then, duplicative tests will keep costing patients pain and payers billions.

* Gene’s personal mic drop: waiting two weeks for a CD-ROM of med records in 2025. That’s why interoperability still sucks.

Final Notes

* Benji is launching a FHIR for Business Analysts course this fall finally, something for the non-technical crowd.

* Bill continues running DMV “FHIRside dinners” and teaching internal FHIR courses.

* And the trio is hyped for the Pittsburgh Connectathon, where theory meets war stories in real time.

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Are you living in a world of broken dashboards and unreliable data pipelines? You're not alone. For too long, data has been treated as a downstream problem, an afterthought to be dealt with by overworked data teams.

In this special deep dive, we're joined by Chad Sanderson and Mark Freeman of Gable AI to explore the solution: the Shift Left movement and Data Contracts. We break down how this new paradigm treats data as a first-class product, creating a clear, enforceable agreement between the data engineers who produce the data and the teams who consume it.

For our listeners in health tech, this conversation is especially critical. Think of the HL7® FHIR® standard itself as a powerful, industry-wide data contract. It defines the precise structure, terminology, and API rules for exchanging healthcare information. Applying a 'Shift Left' mindset means treating FHIR compliance not as a final validation checkpoint, but as a core requirement from the very beginning of the development process. By enforcing the 'contract' of FHIR at the source—before data ever leaves the EHR or clinical system we can build more reliable interoperable systems, reduce costly data errors downstream, and ultimately deliver better value and more effective AI solutions.

Tune in to learn:

* Why the modern, federated data stack broke our old processes.

* How to bridge the gap between software engineering and data teams.

* Practical steps to start implementing a "data as a product" culture that delivers real value to your clients.

Learn More: Our guests literally wrote the book on this! Check out Chad Sanderson's new O'Reilly book, "Data Contracts," for the complete guide. ADDITIONAL Reading

* Gable AI – Data Contracts: Data Contracts Book (Chad Sanderson & Mark Freeman)

* Shift Left Data Manifesto: Shift Left

* HL7 FHIR Overview: HL7.org FHIR Overview

* FHIR Contract Resource: FHIR Contract Definition

* FHIR Profiles / StructureDefinition: FHIR Profiling Guide

Technical Tools

* HL7 FHIR Validator: FHIR Validator CLI

* Gable Data Contract Examples: Example Contract Specs

* FHIR JSON Schema (useful bridge): FHIR JSON Schema

AI + Healthcare Context

* NCQA Digital Quality Ecosystem: NCQA Digital Measurement

* SMART on FHIR: SMART Health IT

FHIR Contracts App

* 🔧 FHIR Data Contract Generator (beta): appA playground to generate FHIR-based data contracts aligned with shift-left methodology.

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Get ready to geek out! This week on "Out of the FHIR," Gene Vestel sits down with the brilliant Kerry Weinberg, co-founder of Phenomenal and a true expert in the trenches of healthcare data and AI.

Kerry and Gene jump right into the big questions: Can an AI really understand healthcare without deep medical knowledge? They explore the wild, unpredictable nature of human health data (it's not your average software log!) and Kerry shares a killer story from her time at Amgen about why context is EVERYTHING when building predictive models.

The conversation then tackles the big one: AI agents giving medical advice. From today's clinician-in-the-loop systems to the future of patient-facing bots, they discuss the promises, the perils, and the fact that the AI genie is already out of the bottle.

Plus, get the inside scoop on the buzzworthy Model Context Protocol (MCP). Is it the next big thing or just a lot of hype? Kerry breaks down the good, the bad, and the tricky parts of getting AI to speak fluent FHIR without making stuff up. This isn't just a tech talk it's a fun, inspiring, and refreshingly real conversation about the passion, purpose, and incredible people building the future of healthcare.

Tune in for:

* A masterclass on the nuances of AI in health.

* The real story behind starting a health-tech company.

* An optimistic look at the vibrant and growing FHIR community.

* ...and maybe even plans for a future live-coding session on Twitch!

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Welcome back to another episode of Out of the Fire Podcast, where we tackle the hottest topics at the intersection of healthcare, FHIR, interoperability, and technology.

This week, I am thrilled to be joined by a true visionary and expert in the health-tech space, Jill DeGraff. If you follow the conversation around healthcare data and policy, you've undoubtedly come across Jill's insightful analysis and forward-thinking perspectives.

In this episode, we jump straight into the topic that's lighting up every health-tech feed: the new CMS Interoperability Framework. Just days after its announcement at the White House, Jill helps us cut through the noise and understand what this "moral commitment" from industry leaders and the government truly means for the future of healthcare data.

Is this just another initiative, or is it the start of a genuine "race to the top"?

In our conversation, we cover:

* The 'Why' Behind the New Framework: Jill explains the crisis-level urgency driving this initiative, from the national disease burden to the economic unsustainability of Medicare.

* What's Different This Time? We discuss why this framework is more than just "TEFCA 2.0," focusing on its shift from slow, consensus-based iteration to a model of rapid execution and accountability.

* "Kill the Clipboard" and Beyond: A breakdown of the key pledges, including the National Healthcare Directory, modern digital identity verification, and the push for a truly seamless patient experience.

* Leaders vs. Laggards: Jill offers a compelling analysis of the business implications, arguing that organizations that have invested in modern architecture will thrive, while those reliant on legacy systems will face significant challenges.

* Career Insights: We kick off the episode with a fascinating look at Jill's career path from law to health-tech, and she shares invaluable advice for anyone considering a career in consulting.

"This is a moral commitment... It's about unleashing the creative energy of the private sector to do what it does best, which is innovate and build value for people." - Jill DeGraff

This isn't just a policy discussion; it's a look at the seismic shift happening right now in our industry. Whether you're a developer, a clinician, a policy wonk, or an executive, this conversation provides a crucial map to navigate the new landscape of healthcare interoperability.

Listen now to get the full story!

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Welcome to Episode 9 of Out of the Fhir! This week, we're joined by a special guest, Eyal Dviri, Head of the Data Innovation team at Clalit Health Services the second-largest integrated payer-provider organization in the world.

In this fascinating conversation, we travel to Israel to explore its unique and rapidly evolving healthcare ecosystem. With a new law mandating nationwide, FHIR-based data portability, Israel is at the forefront of a healthcare data revolution. Eyal provides an unparalleled, on-the-ground perspective on this monumental undertaking, discussing the real-world challenges and strategic decisions involved in modernizing an entire nation's health data infrastructure.

Tune in to learn about:

* The Clalit Scale: The immense scope of managing data for 14 hospitals and a massive community network within Israel's public health system.

* A National FHIR Mandate: How a new law is compelling the entire country to rebuild its data foundation on FHIR, moving from legacy systems to real-time, structured data exchange.

* The AI Race vs. Data Foundations: Eyal breaks down the critical tension between the rush to deploy AI solutions and the essential, foundational work of ensuring data quality and interoperability through standards like FHIR.

* A Unique Patient Consent Model: A deep dive into Israel's planned Patient Consent Manager (PCM) and why putting the patient in control of their data is a non-negotiable cornerstone of their new ecosystem.

* Global Lessons in Interoperability: How Israel's journey offers powerful insights for healthcare systems worldwide, including the US and its TEFCA initiative, on what it truly takes to build a connected health network.

This is a must-listen episode for anyone interested in health data interoperability at scale, the practical realities of implementing FHIR, and the crucial relationship between structured data and the future of trustworthy healthcare AI.

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🎙️ Episode 8 – Why Provider Data Is Still Broken (And How to Fix It) | Guest: Ron Urwongse

In this episode of Out of the FHIR, Gene sits down with Ron Urwongse founder of Defacto Health, a self professed Provider Data Nerd, health tech strategist, and one of the sharpest minds in provider data infrastructure to unpack why provider data remains stubbornly inaccurate, fragmented, and operationally painful across the healthcare ecosystem.

💡 Ron exposes the root problem: most healthcare APIs are still glorified databases with business logic missing from the stack. He explains how data accuracy isn’t just about syncing directories it's about rebuilding the underlying operational model with intention, alignment, and contextual relevance.

🔎 Featured Topics:

* Why provider data is only 50% accurate and why that state hasn’t changed in a decade

* The myth of a universal provider directory and why a national directory won’t solve what’s fundamentally a business logic problem

* How plans, vendors, and digital health players are stuck pushing CSVs and duct-taping endpoints

* What it would take to build an AI-native, agent-based model for provider data stewardship

* The limits of FHIR and the opportunity to use it as an orchestration layer, not just a data exchange format

💥 Key Quote:"You can’t clean up provider data until you change the incentives, rebuild the system logic, and stop pretending it’s just a data formatting issue."

This episode is a must-listen for anyone touching provider directories, network management, quality measurement, prior auth, or digital health operations. Ron doesn’t hold back and it’s the perspective the industry needs to hear.

🎧 Listen now and rethink what it really means to fix provider data.

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Out of the FHIR – Special Edition: Plaid for Healthcare, Part 2 Episode Title: The Infrastructure Awakens: From Interop Dreams to Data-Driven Reality

In Part 2 of our special double-header episode, Eugene Vestel dives even deeper into the bold vision of a connected healthcare ecosystem with two of the industry's sharpest minds:

* 🧠 Brendan Keeler – Interoperability Practice Lead at HTD Health

* 🚀 Jason Kulatunga – Founder of Fasten Health, Techstars NYC '24

We go beyond the buzzwords and into the infrastructure truths that will define the next decade of healthcare:

🔹 Why the FHIR movement is both essential and already obsolete in some ways 🔹 The brutal reality of building consumer-first health tech in a system that wasn't designed for it 🔹 How we might look back in 3–5 years and think, "What were we thinking?" 🔹 Lessons from Plaid’s playbook and what not to copy in healthcare 🔹 The emergence of an autonomous data layer that lets AI act without human crutches

This isn’t hype. It’s the kind of grounded, uncomfortable, and ultimately liberating conversation we need to have if we want to break through the ceiling of digital health and actually build something better.

🔥 If Part 1 sparked the idea, Part 2 sets it on fire.

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🎙️ Out of the FHIR: Deep Dive – Plaid in Healthcare with Brendan Keeler & Jason Kulatunga - Part 1

In this episode of Out of the FHIR, we go deep into the future of healthcare interoperability with two visionaries at the forefront of change: Brendan Keeler, Interoperability Practice Lead at HTD Health, and Jason Kulatunga, Founder of Fasten Health and Techstars NYC alum.

We explore:

* 🧩 What a "Plaid for Healthcare" could really look like

* 🔄 Why control, transparency, and patient-directed access are non-negotiable

* ⚙️ The architectural and cultural hurdles standing in the way

* 📊 How Fasten Health is creating a personal health API layer that empowers individuals with their own data

* 🔮 Where we're headed next and what needs to happen to get there

This conversation is a raw, practical, and energizing look at what it means to rebuild trust and functionality into the healthcare data experience.

Whether you're a product leader, developer, or policy wonk, this episode unpacks the real implications of a truly open health data ecosystem and what it’ll take to get us there.

Listen now, and join the movement.

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🎙️ Out of the FHIR Podcast: Part 2 with Joshua Kelly – Highlights

🚀 What’s Joshua Excited About?

* Payer-to-Payer ExchangeA pivotal shift enabling payers to consume data—not just expose APIs—transforming how charts are transferred and reducing manual burden. Huge potential impact on chart chase inefficiencies and member onboarding.

* FHIR-Specific AI Model Evaluations (FIRE Evals)Joshua outlines Flexpa's work on evaluating LLMs for FHIR tasks like:

* Extracting structured data from FHIR resources

* Generating FHIR bundles from text

* Using reinforcement learning with verified rewards (not RLHF) to improve smaller, private models that outperform general LLMs in FHIR use cases

* FHIR validate operation as a reward signal in reinforcement learning, opening the door for better automated resource generation.

💡 Underrated Innovations

* Smart Health Cards & LinksJoshua sees these as massively underutilized. He envisions paper-based lab results with QR codes enabling seamless data transport—a simple but transformative workflow for patients and providers.

* Patient “Sneaker Net” as an Interop HackPatients as the natural transport layer—bringing their own data (e.g., via QR codes or printed links) could rival national HIE efforts in utility.

* ChatGPT for Patient InsightReal-world use: Eugene shares how he used GPT to interpret his child’s lab results. This is already happening—users are moving ahead of systems.

🏦 Financial Interop Lessons for Healthcare

* OAuth SuccessHealthcare learned from fintech, starting with OAuth, unlike fintech’s slow rollout.

* Why Plaid’s Model Doesn’t Fully Translate

* Fewer, more cohesive accounts in finance (e.g., Amex, Chase)

* Healthcare data is fragmented across insurers, providers, labs, often with confusing branding (e.g., the "Blue Cross problem")

* The Real Challenge? Data Locator ConfusionEven insiders can’t always identify where data lives. This limits the utility of personal health apps or wallets—too niche for mass adoption.

🔧 Tech That Needs More Love

* SQL-on-FHIRJoshua ranks this as his #2 underrated tech (after Smart Health Cards). While not truly “SQL,” it simplifies FHIR's nested structures into tabular formats—crucial when working with bulk FHIR data.

* Flexpa’s Open Resources

https://my.flexpa.com

* : Free tool to access your health plan data

* Flexpa's Payer Directory: Public directory of payer APIs, location access endpoints, etc.

🔚 Final Thoughts

* The promise of interoperability is not just connectivity—it’s actionable insight, better care, and easier access.

* More orgs should share implementation experiences like Flexpa does to reduce duplication across the FHIR ecosystem.

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Episode 4: Unlocking Interoperability with Joshua Kelly

In this episode, Gene Vestel sits down with Joshua Kelly, CTO of Flexpa, to unpack the complexities of healthcare interoperability. They discuss real-world challenges, cutting-edge strategies, and practical solutions for seamless data exchange across healthcare systems. Josh shares valuable perspectives on the future of interoperability, highlighting opportunities to transform patient care through technology and collaboration. We dive deep with Josh into why healthcare is so different from other industries and the critical role terminology plays in interoperability. Plus, we nerd out on issues around coding concepts and the misuse of value sets in FHIR!

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