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 where Cerner is going to launch inside of TikTok, you’re going to have your patient record right there, you’re going to be able to watch new healthcare shows on Paramount Plus. Larry Ellison has a long-term plan here, so I’m not too concerned.

Ryan Tucker (05:45): Bundles on bundles.

Brad Thorson (05:47): It’s just a new bundle. But in all seriousness, they do not seem to be winning, and they still have major customers here in the US, and they’ve been strong in international sales recently. I don’t want to take us down a divergence, but there’s potentially a paradigm shift where whether interfaces that get replaced make it easier for entities to leave their existing system of record is yet to be decided. I don’t think they’re going to get out of the game until they’ve very definitively lost, and they’ve still got enough of a foothold. They’re just going to keep cutting the human beings and hoping the robots come in and do great customer service.

Ryan Brickner (06:33): And to push back real quick on Ryan, and I kind of want Brad’s take on this too. What is Oracle gaining from having Oracle Health as a constituent part of its conglomerate? To me, it does not look like it’s driving more value within them than outside of them, which is the first thing you look for when you’re asking whether it’s time to divest an asset. And I think the public would be willing to value it at a higher multiple right now, because you could focus it on what they do instead of spreading your resources thin across God knows how many divisions they have.

Brendan Keeler (07:15): That’s a great segue to part two of the Oracle question. I’m going to reframe it with the Brendan Keeler history of Oracle so you have a perspective on how we got to this place.

Oracle, the database company, 1979, auspicious year, as that is also when Epic was founded. That’s what Softwar, the big book everyone talks about, is really focused on: how did they muscle their way through things with these aggressive sales tactics as they sold database technology and oftentimes oversold database technology. That’s what they were known for, and the stock did great all through the 90s.

Phase two: Oracle, the horizontal application company. Seeing that database technologies and sales were changing and that things were moving into software, they started to release the E-Business Suite. ERP, HR module, general ledger, all those things. That was the 90s into the 2000s.

In the 2000s their strategy shifted to vertical-specific software. Phase three. And they have tons of Oracle Healths. They have Primavera in construction. They have Aconex in construction. They have Siebel, which has fallen behind Veeva and others in clinical trials. They built systems of record as the dominant enterprise systems of record across almost every major vertical. Not all are popular in the US, some are popular internationally, some domestically, but that was phase three.

Phase four, people forget about this one: hardware. Purchasing Sun Microsystems in the late 2000s and other purchases. Did they ruin Sun? There’s fun dialogue to be had there, but that underpins some of their prowess for building data centers and cloud.

The 2010s, the next phase, is cloud. And everyone laughed at Larry Ellison for nearly a decade as he pursued cloud and was a distant number four. How will he ever win? And it turns out the right win for cloud for them was that all of those vertical-specific softwares transitioning to cloud logically go onto Oracle Cloud Infrastructure and then are nice enduring businesses, even as some aren’t as successful in winning new customers. Those are sticky systems of record that stick around for a long time.

And then now we’re in the last phase, where they’ve evolved even further down the stack. We have this Oracle Cloud Infrastructure, we built a lot of data centers for it, let’s go sell those data centers to other buyers, AI buyers. That’s the past two years. So we’ll put aside Paramount and TikTok and other side ventures into the consumer space.

Brad Thorson (10:13): That’s David Ellison’s work. Larry’s staying on the server side.

Brendan Keeler (10:18): That’s David Ellison’s work, that’s right.

Ryan Brickner (10:19): Right, but putting up all the collateral. Side quest.

Brendan Keeler (10:22): So that conglomerate, I think that’s a great use of words, Ryan Brickner. That’s a conglomerate. Multiple diverse business units that ebb and flow and can offset each other’s weaknesses. I think the challenge here is that conglomerates work where they’re ebbing and flowing, and right now the data center pull is tremendous. It’s unstoppable. There’s a zero on top of everything else in the conglomerate.

So with that in mind, do you change the strategy? If you’re saying sell Oracle Health, the question comes, well, why wouldn’t you also sell other vertical-specific software business units that are going through not as bad of struggles? Certainly Siebel, or whatever it’s called now, isn’t winning against Medidata and Veeva. Primavera is the master schedule that’s in every construction site but is kind of viewed as legacy, the schedule’s always out of date, and it’s certainly going to be under threat from Procore and others in coming years. The same shape exists.

My thesis is they’re okay eating that because it powers cloud and thus powers their build. There are some synergies. So with that very lengthy history of Oracle as told by Brendan Keeler, are your answers changed at all, or are you sticking to your guns?

Brad Thorson (11:44): We can’t see our audience raise their hands, but I imagine more than a couple of you use Claude Code or Cowork or whatnot to have a raucous good time building fun web apps. The value of the data they’re sitting on across all of those applications, not necessarily what is Brad’s weight on any given year that he goes to see his PCP, but the metadata, the workflow, et cetera.

I don’t know when we’re going to actually see their AI-first EHR, but they have models that are going to want access to that. We saw Google pay what, ten million dollars for call center logs from Spirit Airlines as a testing ground for agents. If Larry Ellison really does believe that AI agents are going to be this massive disrupting force and he doesn’t need to have humans at his company anymore, having these systems of record, even if they are legacy, is of tremendous value in the very near term. And health data, we produce petabytes worth of it on a regular basis. That is a perfect thing for them to be sucking up and trying to work with, even if their applications aren’t particularly loved or purchased in high volume here in the US.

So I still see it as a long shot that it’s going anywhere, especially because they are the 26th largest country. They can wait these things out. I don’t know if Ellison has the same level of shareholder status as Mark Zuckerberg, permanent king of Meta, but he’s not going anywhere. He’s already investing in living forever, and so I think he’s going to try to have his various companies live forever. I’m staying put.

Ryan Tucker (13:32): “Wait these things out” is a very good point, Brad. And I was trying to be concise with my answer because I got plus two points on the first round. So, dead, that was the very quick take. To be clear, I think it’s dead in terms of a net new revenue generator within the next decade. I don’t think there’s a lot of growth there. It’s not growing. So I think hold is probably the right position, because I don’t know if you necessarily want to bet the house on everything else, just AI data centers, selling everything off and only going within that vertical. I think that’s risky amongst the whole market, and we’re going to see how that plays out in the next decade. But I think it’s more hold versus trying to find a buyer. I don’t know who would fit as a buyer. All that with the caveat that, as I pass it to Brick to probably disagree, I’m not the one getting an MBA. So I will admit that I’m probably not the right one to have a take here.

Ryan Brickner (14:30): All of those are very fair points, because in a vacuum it probably does make sense for Oracle to hold on to Oracle Health. And to avoid saying Oracle Health over and over, I am just going to revert to calling them Cerner from now on.

But we don’t live in a vacuum. We live in a world where Oracle needs money. They need cash on hand to fund their investments, to fund their AI infrastructure. And you look at different ways to raise money. You could issue debt, which I don’t know if they want to do at a time when interest rates are generally above where they’ve been recently. I don’t know if they want to sell stock right now, it’s taken a beating recently, and selling stock necessitates watering down all your existing shareholders with the intention of using that money to increase shareholder value later on. Or you start selling off assets.

And I think you have an asset in Cerner that’s been bringing them in front of Congress for not good press, and bad press overall with the rollouts at the VA. It’s generally a headache that they could divest, and they could either forgo those other fundraising opportunities or use it to hedge those and lower the risk elsewhere, while unloading an asset that, while it does have synergies with data centers, especially with the vast amount of data there, brings them into a very regulated area. They could get rid of it and go back to their roots as everywhere but nowhere that’s super regulated. Same reason a lot of places start selling off their financial arms. You don’t want to deal with the side effects of being regulated as a bank if you don’t need to. So Oracle, why bother being a holder of all this health information for your provider customers if you don’t need to?

Brendan Keeler (16:42): Some great strong answers here. Time to assign points for the last two rounds. We’ll give Brad three points for really zigging with another zag. Ryan Tucker, I’m going to give you one point. Brickner, sorry, zero points, and I’m going to give you one point for round two because you stuck to your guns. But they’ve issued something like forty-six billion in debt. They’re pretty deep in issuing debt at this point, pretty far down the road of every financial contraption to raise money, including customer prepayments, supplier financing, and an equity issuance. They’re pulling everything they can. So I’m going to give you the extra bonus point because you’re right, at some point they’ve tried every lever except selling something.

Round two, Ryan Tucker, I’ve got to give you zero points, because you hedged. You hedged really hard. You didn’t trust yourself. You said “I’m not the MBA.” You’ve got to own your take, because it was a pretty good one. And Brad, I’m going to give you two points for your winding dialogue there.

So here’s the last Oracle question for the day. Who would buy Oracle Health? We said we can’t figure it out. We can figure it out. If they were to sell, who’s the buyer?

Ryan Brickner (17:57): I’ll start us off, and this is more of an “I would like for this to happen” than where I think it’s going to go. But IPO is historically the way that people cash out of their investments. So I’d love to see them just become a standalone public company. I cannot remember if they were before Oracle took them over. The other alternative is another EHR being sucked up by venture capital, and I don’t know if that’s the right answer. I’m sure somebody is going to take that bet, but I don’t know if in the long run that’s what’s going to be best for Oracle Health or Cerner. So I’d love to see them IPO.

Brendan Keeler (18:46): They did IPO in 1986 as CERN, so they were public for some time. Alright, who wants to go next?

Ryan Tucker (18:57): I love the Ryans, so I don’t want to be just disagreeing with Brickner the entire podcast, but IPO seems tough. After five thousand plus laid off, they’re paying like seven hundred million dollars in severance. It just doesn’t seem like the right time to announce a public IPO.

Who could be interesting: someone who has explored health many times over the decades, never fully dipping their toes in, but who competes with Oracle and has been trying to get more into the health space with some of their device acquisitions. I think Alphabet might be an interesting one. I don’t know how well it would work, but they love having the data that works well with their other application flows. I don’t know if I’d want to see that, but I think that could be a buyer.

Brad Thorson (19:48): I’m putting myself in realistic boundaries here. The buyer has to be FedRAMP certified, so that narrows who can buy it. And Amazon and Google are out purely from the fact that there’s been so much work to migrate to Oracle hardware. So I’m going to throw a wild curveball in here, because I just went and Googled who’s FedRAMP certified and did a quick scroll. I’m going with IBM.

Brendan Keeler (20:20): Whoa, tell me more.

Brad Thorson (20:22): Big services business. Very questionable investments into AI. They have a ton of cash on hand. Their stock is not doing... I’d have to go look, but I feel like their stock is not doing that great. Last I heard, Claude being able to write COBOL code knocked a couple hundred million off their market cap or something like that.

They have a large consulting and services group that can go in and work with these hospitals and help implement the tools. And I don’t get the sense, and I could be totally wrong, that they’d have a big issue with using Oracle as the hosting vendor. They’ve got Red Hat somewhere still in there. So my bet is IBM.

Brendan Keeler (21:11): That would be a fun twist, to hand it off to such a staunch former rival in the database business. Alright, for points: Ryan Tucker, I’m giving you two here, I think that was a nice take. Brad and Ryan Brickner, I’ll give you both one for creativity.

The obvious answer to me is actually adjacent to Ryan Tucker. Google is kind of like Oracle, but with a bigger AI business and more consumer facing, so they’re actually kind of less equipped potentially to run a vertical software business. They don’t have any others. Oracle has many. But what about the AI labs? What does an asset like Cerner do for someone that has a wealth of cash, in terms of being able to train models and do really novel stuff, to take the AI work that Oracle has infused and run it to its fruition in ways that they or even Oracle couldn’t? There’s a big-brain mega-brain take there of “Claude on Cerner” or something that could play out, and they certainly have money. At the bare minimum, they’re able to train on those data sets.

Brad Thorson (22:28): I’d be interested in somebody a level less abstracted. I view the amount of work OpenAI and Anthropic have gone to with all the major consulting firms, to go in and do the work to implement these tools with businesses. Cerner used Deloitte, so sure, it exists there. But I’d be interested in people who are building application layers. I don’t have a good answer.

Brendan Keeler (23:01): Okay, for that deviation, I’m docking you a point. Now let’s go to Brickner.

Ryan Brickner (23:08): Brad, I’m glad you chimed in, because I was about to say that would totally be something up Sam Altman’s alley, an acquisition of Oracle. To the Google point though, I think they are scarred over their last attempted entrance to health. So I don’t think Google touches it with a thirty-foot pole.

Ryan Tucker (23:27): Which one? They’ve had like multiple.

Brad Thorson (23:31): They’ve had a billion, yeah.

Ryan Tucker (23:34): So why not try again? It could work this time.

Brad Thorson (23:37): Fitbit will buy it.

Brendan Keeler (23:39): It is different, right? It’s different to do consumer PHR, consumer health, virtual care through some of the Alphabet companies. A vertical system of record is a very different business than most of Big Tech has ever tried. Apple doesn’t have vertical systems of record. Google does not, really, outside of maybe Google Workspace. You could say Google Docs is kind of an organizational system of record, weak, definitely not verticalized. Really the only one taking cracks at it is Microsoft, so maybe out of Big Tech they’re the one with closer lineage. But Oracle was the one out of Big Tech that had the right lineage to go and run with this.

And I think they continue. Much like Constellation owns a ton, their whole business as pseudo private equity is to buy systems of record across every industry worldwide and then just milk them indefinitely, because people don’t switch. In that light, if you view this as funneling into Oracle Cloud, data centers, et cetera, then maybe that’s it. Maybe this is just a different angle on what Constellation does.

That’s it for Oracle. Let’s move on. We’re getting deeper, the scores are starting to rack up and rack down for different people. The next question is, we’re talking a lot about AI, the AI labs. Will AI kill the world? Are we doomed? That has been all over the news, with Anthropic coming out very viscerally about the threat and needing to slow down. We are hardly the first people to talk about this, but let’s strike while the iron is hot. Are we doomed?

Ryan Tucker (25:28): Can I ask a question of our moderator? Do you have a time horizon in mind?

Brendan Keeler (25:35): The question is not time horizon. The time could go quicker. According to Dario and Sam Altman, we need to pace it to prevent that time horizon from being too soon. That is part of the allure and mystique of this dangerous promise from our frontier AI overlords. Brad.

Brad Thorson (25:55): I’ve not read the piece, but Matt Stoller wrote something like “stop worrying about AI.” I’ve heard a lot of podcasts talk about the article, so I feel very well educated.

I think there’s a case to be made, I don’t know that this is all marketing hype, but these frontier labs are spending an enormous amount of money on the next model they’re going to release. Google seems to have pulled their foot off the gas a little bit, maybe because they’re hitting a limit with current methods on improving their models. And so it would be really good for companies that need to IPO, like Anthropic and OpenAI, to not have to continue to spend an ass load of money every single day training new models. That’s a very specific amount of money. So part of me thinks maybe we’re really blowing this up and we want to put the brakes on so that financial performance looks much better in six months’ time.

But when I read or hear about the hacking incidents, particularly at Hugging Face, it starts to get pretty dystopian, that these agents created their own messaging board and were suggesting to each other to kill themselves for the greater good. It’s a bit of anthropomorphizing, can’t say that word. My p(Doom) is not at ten percent like the guy from Anthropic, but I certainly don’t have confidence that everybody at the frontier level is concerned about the survival of humanity.

Brendan Keeler (27:24): Balanced take. Okay. Ryan Brickner, you got anything?

Ryan Brickner (27:30): I think Brad hit the nail on the head. The way I’m thinking about the decision to come out and say we need to slow down and AI is going to destroy the world, I’m taking it in two parts.

The first part, I think it’s entirely financially motivated. Look at the prisoner’s dilemma. Right now they are both losing, because they need to invest money over and over so the other one doesn’t eclipse them. They both stand to benefit if they could come to an agreement, and without being able to come up with an agreement between those two, because I’m sure that has collusion impacts, you have the government tell you both to slow down and then it’s perfect. You both save money and you both get to reap the rewards in the IPO phase.

As far as “will it kill us?” No. That is sensationalist. People have been saying this for as long as humans have been alive. First the robots were going to kill us, then the internet was going to kill us all somehow. I’m sure when the machine-powered drills came out, somehow those were going to destroy the world.

Brad Thorson (28:32): I mean, we keep trying.

Ryan Brickner (28:33): We are a resilient species, and I don’t think we’re going down to a bunch of computers. Maybe the data centers, just from the sheer amount of energy they’re taking, expedite global warming and that takes us. But AIs themselves are not going to be what does us in.

Brendan Keeler (29:04): Ryan Tucker, you have the bold task of coming up with a novel take here. What do you got?

Ryan Tucker (29:12): I don’t know how novel it is. I think we are doomed, but I think we’re doomed in microcosms.

I read a book probably over a decade ago called Weapons of Math Destruction, I think it’s Cathy O’Neil who wrote it. This was around the uses of algorithms, before LLMs and big AI and everything, but it talked about how folks on the margin, outside what a model is trained on, always suffer when it comes to the implementation of that algorithm. There’s stuff around US News and World Report and how folks got into college based on the ranking system and what attributes it would select for a college. There’s stuff on race and us in healthcare. Even when we were training a risk score before it was AI-based, if you’re training a risk score based on the majority, folks who are maybe a different racial profile, different age, different sex than what the model’s actually trained on, the recommendation is not correct for them.

So I think we’re doomed in microcosms first, the economic bubble, those types of things, before the killer robots are knocking on our door. That’s what I’m more worried about than the greater-scale death of humanity.

Brendan Keeler (30:27): All solid takes. I personally am excited to live Maximum Overdrive, the 1986 sci-fi horror where all the machines come alive. To your point, how could everybody be wiped out? Like really go extinct? I’m ready to go John Connor on this s**t. We can survive for a pretty long time. Extinct is bold. Massive harm, yeah, I think they could inflict massive harm quicker.

So, points. Ryan Tucker, great reference, a little academic, I was getting bored, but then you really brought it home. Three points. Brad, you get two points for giving the opening take and a really good one. Ryan Brickner, I’d give you one for tailing them, but you said it really succinctly, so up to two points for you.

Okay, that is it for AI. Next up, this is a phone a friend. Nathan von Colditz, friend from Portland, he’s in health tech on the payer side. He phoned in and asked us, in our esteemed wisdom, to explain why, when you’re at an Epic system and you show up for your appointment, and it’s clearly linked to other Epic systems and pulling data over health information exchanges, you’re filling in the questionnaire all the same with your medications and such.

This is something that underpins the Kill the Clipboard initiative, this de novo technology part of the CMS Health Tech Ecosystem, showing up and handing over the data to be imported. But the data is already there in some form. So let’s take a crack at it. Let’s go through a round and each try to explain some different reasons why you’re still inputting data all the same.

Brad Thorson (32:13): This is unfair because of Ryan Tucker and Ryan Brickner’s previous jobs.

Brendan Keeler (32:18): Not everything in life is fair, Brad.

Brad Thorson (32:23): I’m still going to win, because it is frustrating to enter that information and I’m not saying this is always the reason why, but there are signals in the actions that we take, the metadata around this. If I put in my medication information and then I go into the visit and the doctor asks me, hey, are you still taking these medications, and I’m like, yeah, I forgot about that. That’s something they’re using. That’s context for their AI model and their brain to try to figure out what to do with me. Maybe I’m not very adherent to my medication, and they wouldn’t have had a signal that that was the case if they had just imported my medication history from an HIE. So I think there’s metadata around these forms.

Brendan Keeler (33:10): Strong way of sliding in there before the Care Everywhere dogs come in to answer it. Love it. Alright, who wants to go next?

Ryan Brickner (33:18): Brad, I’m just going to ask you real quick, do you just define thinking as the AI model in your head?

Brad Thorson (33:25): Yeah, obviously. Our brain is the most computationally efficient AI model on the market and we need to use it more.

Ryan Brickner (33:38): I think you’re cheapening our brain work by comparing it to the AI models.

Ryan Tucker (33:38): Maybe your brain.

Brendan Keeler (33:44): I know my context window is really small, I’ve learned. So Brickner, you’re up. What do you got?

Ryan Brickner (33:50): I want to bring up an anecdote I heard the other day from a dentist. A patient presented and something didn’t seem right to them, so they went and got the patient’s medical records and saw that the patient’s on like forty different medications. So they go and ask the patient, hey, I just got this giant list of medications from your provider, why did you tell me that you’re not taking any? And his response is, well, yeah, but I’m just not taking them. That kind of context is lost if we’re just pulling in the information without the context of the patient. You always need the patient to weigh in.

Brad Thorson (34:30): See, you don’t have to work on the Care Everywhere team to understand how this works.

Brendan Keeler (34:36): So are you saying you agree with Brad? Is that the answer, Ryan Brickner?

Ryan Brickner (34:40): I can’t say that twice, so I’m going to add another caveat. Sometimes timing and system capability is the problem. On the timing side, in order to make these queries over national networks, generally you have to be in front of the provider. So if the questionnaire you’re filling out happens beforehand, before they’re, not legally able to query, but before the network agreement says you’re able to query, they’re not going to have it.

And then the system may not have the ability to pull all of this information discretely into the questionnaire, because that’s another development effort that a lot of them have not done. Instead they just put it into a nice little, I don’t know, holding cell. I hope nobody from the old Care Everywhere team is listening to this, because they’re probably going to tell me I can’t use that term for where the things hang out before you do something with it.

Brendan Keeler (35:41): It’s called prison now. It’s called data prison, where they hold it.

Ryan Brickner (35:46): Well, that’s not good, because it constantly escapes into the chart, which is a good escape. So not quite a prison. But getting it into those questionnaires is probably a lot of dev work for not a lot of benefit, because you still need to bring the patient into it. So why bother?

Brendan Keeler (36:09): Alright, Ryan Tucker, what do you got?

Ryan Tucker (36:11): Brad, I think you completely missed the question. And Ryan, I think you maybe half missed the question. The question was not around med adherence and going through the med list with the provider. It was Kill the Clipboard. It was filling out the form while you’re waiting at reception. Why is my information not already there, and why am I filling out the same thing over and over again?

Yes, it helps to have patient context at the time of the visit to clarify which meds you are or are not taking. But we’re speaking more of the admin workflow, why systems aren’t working and talking to each other. That could be for a number of reasons. We have the Care Everywhere background, Ryan’s here, maybe auto-query didn’t finish that day, your work queues are backed up and the data just didn’t get there.

I think it’s more than likely not technical. It comes down to an implementation and training issue at the office you’re going to. The provider doesn’t know how to pull in data. The front office may have not even looked to see that the data actually is there. And that’s just what they do each day, they hand out the clipboard. It’s not user error, but a user following the same process, not aware of the new process, maybe too lazy to go through the new process. So it’s just easier to give you that clipboard, have you do it each time, and put it in.

Ryan Brickner (37:39): But if it’s admin workflows, the providers don’t really need to know the administrative workflows, and they could just pull it into the system. Really, what I think it is, is that any data older than this moment is out of date. If you were seen somewhere even a month ago, you may have moved in between. And there’s a lot of friction there. It’s easier to get all the information from you up front than to go back and correct it, and if you don’t, you run the risk of continuing to perpetuate wrong information. So if it’s admin workflows, I think it’s a lot easier to just collect it from the patient on a clipboard, rather than risk perpetuating wrong, bad information because you assumed the last person was correct.

Brad Thorson (38:29): Speaking of perpetuating wrong, bad information, I do love looking at my own problem list and seeing that “annual physical” is on it, which is a very interesting problem to be carrying.

Brendan Keeler (38:41): What is your doctor trying to tell you? Alright, points. Brad, boldly snaking that one going first, maybe one point. I did get a little bit of the Billy Madison “one of the most insanely idiotic things I’ve ever heard” vibe, especially when Ryan Tucker basically just said that to you. I’m not going to dock you points there. I think you took a good cut and gave some good fodder. Ryan Brickner, between all your inputs, definitely one point, and I’m going to dock you a point for following Brad into that mess, though. You should have known better. And then Ryan Tucker, I’m going to give you two and then dock you one for being mean to the other guys.

Ryan Tucker (39:23): It’s Around the Horn!

Brendan Keeler (39:25): Fair enough. Maybe we’re too nice here. One thing I’ll say is that the pulls over the HIEs are Treatment purpose of use, which entails a provider reviewing the data. Surfacing that unfiltered in the patient workflow is technically on the verge of IAS, Individual Access Services, and patient access. I think that’s prevented some people from just funneling in all the CDA content, the meds, the problems, for validation by the patient, which would be technically not trivial, but very doable. So purpose of use is one of the commingled things in there, which Ryan Brickner alluded to a little, so I’m going to give you a bonus point for that.

The follow-on question is, Kill the Clipboard is coming. We’ve seen it come to fruition over the past year in the first round of the health tech ecosystem. It can largely be expected that it might be in HTI-6 in some form or fashion, some requirements there to broaden it to the industry. Is that the right answer? Will that solve the problem, when I show up and I’m just clicking “yep, still on this med, nope, not on this med” as I go between institutions?

Brad Thorson (40:39): Ready to jump in. Anybody want it?

Ryan Brickner (40:44): No, go right ahead.

Brad Thorson (40:46): If the problem is, do we think patients are not going to get health care because they have to fill out information in the waiting room, versus time to get an appointment, or simply not engaging with the health system for some other reason, those feel like much bigger problems for us. If we’re talking about federal policy being about bending the cost curve, I don’t think that ink to write on a piece of paper is actually driving that much cost.

So I welcome it as a patient. I do all of my forms via MyChart. I do find it annoying that I have to continually fill out the same things. But speaking for myself, or actually speaking for my husband, I don’t feel good health care frequently enough. I would like to see the initiatives around this be a little bit more focused on treatment, or lack of treatment, issues.

Brendan Keeler (41:43): Any responses?

Ryan Tucker (41:45): I like that take. I’m much less concerned on the patient side. As I go to be seen, sure, it’s a little annoying to have to do the clipboard. And is it killing the clipboard if I’m doing the pre-visit questionnaire on my phone and still going through the whole rigmarole? Probably not, but theoretically the paper clipboard has been killed there.

I’m much more concerned, and I think what should be prioritized, is the treatment side. The actual flow of information between where I was last seen and where I’m being seen now. Relying on patient-reported updates around their health, what meds they’re taking, that kind of thing, is risky and should not be the main priority. It should be having the whole picture of the patient, which the patient themselves cannot present. And we know that especially with older folks...

Brendan Keeler (42:39): I’m going to mute you here. Paternalism is not accepted on this podcast and on this Around the Horn. I’m just kidding. That’s a fair take. Ryan Brickner.

Ryan Brickner (42:47): I will start this out by saying that Kill the Clipboard is not my area of expertise, but the thing that kills me about Kill the Clipboard is why we try to do this with QR codes, whatever they’re called, SMART Health Cards. We’re already exchanging through the national networks with no QR codes, no whatever they like to call it. I feel like they’ve actually taken a step back from a lot of the health exchange that we’ve spent a lot of time getting to, because they don’t fully know what is able to be exchanged right now and how it gets exchanged.

Brendan Keeler (43:31): There are a lot of potential cynical takes about why data has to flow through the patient application to get to the other side, and power games, but giving patients agency is additive.

So, points. Two points to Ryan Brickner for some hot takes, then docking you a point for sort of admitting fallibility, lack of confidence. You had a great answer, so you’ve got to own it. Brad, we’re going to give you two points here, jumping in, strong takes, also being willing to jump in and then defer to others. Very noble of you. Ryan Tucker, zero points. You had a great take, but a little too paternalistic for this podcast.

Alright, last question to close this out, this very fun, unique format we’ve tried here. CMS Health Tech Ecosystem. I’ve sent you all the link to the pledge categories if you’re forgetting them a bit. There’s so much in here, especially as it gets stuffed with new categories from July’s event. What’s the most important thing here that, at the end of the Trump administration, it’s driven not just to POC but also, using other regulatory tactics, to ubiquity? What do you see as the most important or most interesting thing that could be accomplished by the CMS Health Tech Ecosystem?

Ryan Brickner (44:52): Brendan, I don’t even need to look. I was watching the announcement, what was it, a month ago, and the announcement of the diagnostic-quality exchange of imaging is where they need to put their focus. I don’t care about QR codes, but what I do care about is the fact that right now there is not a good way of exchanging diagnostic-quality images. I believe Epic just announced their own version of it, just between Epic systems. But even then, a month ago I was asked to go back up to Wisconsin, get a CD with my MRI results, and bring it down.

I am far from the only person that’s impacting. Being able to reduce the patient as the transport vector, being able to reduce duplicate scans and duplicate procedures, is probably the most impactful thing they could focus on. And especially here, because it’s such a technically complicated area, this is the exact right place for them to come in, focus, and align resources.

Brendan Keeler (46:04): Solid take, no complaints there. Ryan Tucker, you look like you’ve got something, maybe.

Ryan Tucker (46:09): Well, it’s got to be Friends of the Ecosystem, right?

Brendan Keeler (46:13): Just to explain it.

Ryan Tucker (46:15): That deserved the mute. No. I think ACCESS. I think ACCESS would be an important one.

Brendan Keeler (46:23): We can come back to you. We’ll come back to you.

Ryan Tucker (46:25): Yeah, let me think about it for a second.

Brad Thorson (46:28): I’m drawn toward, and these are all new categories, or we’ve carved out space, everything involving pharmacies and pharmaceutical benefits. I am deeply skewed by previous work and just seeing the direct cost of being able to get your medication, taking your medication. The cost of drugs is an enormous strain on the system.

We’ve seen evidence that when patients are given pricing across a number of locations, they are able to make the best choice for themselves, whether that’s “I need it fastest and I’m willing to pay for it” or “I have time.” And pharmacies are pretty dislodged from care delivery, but in the HIV space, we’ve seen in rural Oregon, because Brendan’s based there, places like Albertsons end up being tremendous drivers of bringing patients into the health care system. If you need a medication, even over the counter, you’re going to find a lot more pharmacies than urgent care centers or hospitals. They’re fantastic vectors for getting populations that have difficulty accessing the health system. And in HIV care you see your pharmacist significantly more than you see your provider, so they recognize when things aren’t going well for you, or when you’re delayed picking up a medication. We’re going to go really off the rails here, but the US Postal Service is responsible for finding more lost children than any other agency, because they’re in neighborhoods, they know what’s going on.

Brendan Keeler (48:05): We’re done with that digression. We only have a minute or two left and we’ve got to give Ryan Tucker his chance to redeem himself and earn the win.

Ryan Tucker (48:16): Alright, I found a good one.

Brendan Keeler (48:19): Brad, in the show notes we can share the postal service thing you were going down. So Ryan Tucker, what do you have to pull out the win?

Ryan Tucker (48:26): That was quite the rabbit hole there. I like price transparency. That’s an additional use case, and I think we’ll accept that. I personally have had to leverage the No Surprises Act in the past to get an anesthesia bill knocked down from like four thousand dollars, because it was an out-of-network provider even though my procedure was with an in-network provider. It’s crazy. The system’s crazy. If you don’t know about the No Surprises Act, if you aren’t close to health care like me, you probably just have to foot the bill. We’ve got to get better on pricing for patients and not making medical debt completely destroy your life.

Brendan Keeler (49:05): Alright, solid answer there. We’ll start with Brad. Brad, two points. I was going to give you three, but then you started to ramble a bit. Ryan Brickner, we’re giving you three points. Great, crisp answer. You knew it, you knocked it out of the park. Ryan Tucker, we’re giving you two for the second answer, a bonus one for that initial joke, very funny, and then we’re docking you one for not actually having locked and loaded your true answer.

So, no idea what the scores are. We’ll add these up after the fact and we’ll see.

Ryan Tucker (49:36): I was going to ask if you were tallying.

Brad Thorson (49:38): I have been. And I’m very excited about the results.

Brendan Keeler (49:44): We will definitely, maybe, for the viewers, add this in with fun graphics.

A couple of things I want to note. I’m partial to modern scheduling, you’ll see that on there, about allowing scheduling in an open way. Not a reality today, but if you’re a point solution looking to schedule into EHRs, particularly Epic with decision trees, maybe there’s a consultancy out there that could help you fill those slots. Reach out at htdhealth.com. That’s our sponsor, HTD Health.

The other thing I’ll note is that Brad and I will be in Brooklyn next week on Wednesday, hosting the happy hour. So if you’re in New York City and you want to hang out with the HTD Health crew, make sure to sign up and attend.

That’s it for this episode, and see you on the next one.

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 Art or Emmie or Penny or Ergo or you name it, do third party applications have equivalent access to do the same things and have the same data? That will be the great test of our time, both for Epic and every other EHR subject to the information blocking statute.

Brad Thorson (06:48): It sounds like Ergo sits on top of Art, Emmie, Penny, whatever you want to plug into it.

Brendan Keeler (06:54): Brickner, what was your favorite from UGM?

Ryan Brickner (06:56): Definitely biased on this one, but I think the ability for Emmie to make post-discharge calls to patients is a huge step up for a lot of care coordination workflows. One of the single most expensive parts of our healthcare system is patients that get rehospitalized because nobody followed up with them after their first hospitalization to make sure they’re not right back in there three days, a week, a month later. Having the ability to automate these workflows instead of having somebody spend time on the phone again and again is going to let them follow up with these patients and get them the care they need faster. And it’s gonna free up a lot of man hours to work on specifically the patients they need to focus on, while still not letting the other patients fall through the cracks. I did a ton of work on pop health and post-discharge workflows at Epic, so, tiny bit biased, but I love the direction that’s going in. And Pryce, what was your favorite?

Pryce Ancona (07:58): We’ve now mentioned two things in a row that piqued my interest, because there’s another vertical of solutions that Epic is trying to box out. Of course Epic is gonna say they’re focused on their customers and providing them all the tools they need. But when I’m hearing about the post-discharge calls, I’m thinking about some of the automated AI care navigation products on the market today. Hearing about the fact that they’re gonna start taking payments, doing payment transactions so they can potentially box out payment on-ramps for their customers. They are moving into autonomous coding, which was particularly surprising to me because, Brendan, we talk about how Epic is a massive system of record and they have tons of experience in the operations of the space, but oftentimes, aligned with your comment about them partnering with UpToDate, they’re looking to outsource someone who’s gonna do the crunching and machine learning on what codes should be on what claims. That’s Inovalon and that’s R1. To hear about all of that stuff starting to happen within the software suite, it’s like, no wonder the FTC is coming for ‘em.

Brendan Keeler (09:15): Every article is like, where’s the discussion of the FTC investigation? And I’m like, if they’re under a Civil Investigative Demand, I don’t think they’re allowed to talk about it. So what are you expecting? “Yes, we are under investigation and here’s what we’re saying.” The expectations there were kinda whack. UGM is not about talking about your active litigation. Let’s be clear, if Epic had that conference, I would be there in a heartbeat. But that, and the drama around Sumit and Seth Howard, I wasn’t expecting them to say anything about it, and I don’t know why people were. Then there’s continued bundling, which systems of record do. And they do it not just in healthcare. I wrote an article about property management systems and the lawsuits there where they’re doing it today. It happens, but Epic and any market dominant organization are held to different standards of competition and anti-competition under antitrust laws. So is the bundling they’re doing anti-competitive? Is it plain vertical integration that can be competitive, as we’ve seen through Microsoft? It’s gonna potentially be litigated with the FTC if they think they have a case. It’ll be hard, because the paradox of antitrust for systems of record is that Epic still isn’t at seventy five or eighty percent market share unless you really gerrymander it. So can they gerrymander it? Can they get the market definition over the hump? It’s being tried already in private cases, but the FTC has the same barriers if and when they decide to use antitrust. So, not in scope of UGM.

Brad Thorson (10:47): Or Flower Pot takes off and absolutely eats up. Jump in.

Pryce Ancona (10:51): That was where I was gonna go next. First of all, the payment integration I mentioned is called Epic Savvy. Thank you, Brickner, for reminding me of that. And then eFax is another one that I’m now looking at on John Lynn’s Healthcare IT Today article, another on-ramp you could potentially box out. These are point solutions that Epic is starting to serve in some form or fashion. But Brendan, I’m particularly interested in your macroeconomic perspective. Epic is continuing to try to go down market with these smaller and smaller plant names. It’s either poems or plants or something. So Brendan, what was your take on this?

Brendan Keeler (11:27): Okay, you go after market segments. You say, “What is the best route to go after this segment?” That’s usually how you do it. Instead they’re saying, we’ve got Sonnet, which is a reduced feature set. We’ve got Garden Plot, which is a hosted environment where you’re multi-tenant with other similar provider groups. And then you have Orchard, where it’s a hosted environment pre-wired to all these third parties, but you’re single tenant, you’re not with somebody else. It’s just quicker because we pre-wired a bunch of stuff, like your clearinghouse or whatever. They’ve tried these over the years. Sonnet they first tried in like 2010. They tried it again when I was at Epic. Apparently she said it on stage, but then some intelligence came in from people saying, no no no, Sonnet was ripped out a couple years ago. So what are they talking about? Is there something new coming? I don’t know why Sonnet is still around. They need to stop trying to make Sonnet happen, for sure. And they probably need to consolidate around the strategy that’s gonna help them. I can give them Garden Plot and Orchard, because maybe there’s a different buyer for multi-tenant hosted versus single-tenant hosted. But disambiguate it, clean it up, go to market with what’s working. I guarantee there’s gonna be tons of appetite for Orchard’s business model. That’s a really nice middle ground for mid-market providers in my mind.

Pryce Ancona (12:46): My next question becomes, is Epic actually ready for that? You really don’t compare Epic by and large from a competitive perspective. You can’t really compare Epic and athenahealth, right? They’re serving pretty darn different markets. Of course they compete in a pretty big Venn diagram, but I’m thinking of one decently sized clinic assessing Athena versus Epic. One of them is bigger as a company, one of them has more hospital beds. Does that matter to a 10-clinic practice? I have no idea. Could they fall flat and just overprice? Not sure, but obviously they’ve thought about it a little bit. So, excited to see where that goes.

Brendan Keeler (13:25): Does the same type of person who buys a Rivian buy a Chevy Malibu? Different market segments with different products for those market segments exist because of different needs. If I’m out living on my farm and I need a truck to get stuff around, versus I’m in the city, well, trucks are more popular than ever, but it’s space constrained and I have different buying inputs. Me as a single-doc practice needing software to run my business is the pickup truck to the Chevy Malibu of inpatient care.

Pryce Ancona (14:01): Don’t tell me my Chrysler 300 looks like a Phantom. Or the other way around. What else? We briefly touched on how people were overfocused on expecting Epic to step on stage in front of 11,000 people and start talking about all their dirty laundry. But it was notable, according to many, that Seth Howard led the segment called, what’s it called?

Ryan Brickner (14:29): Cool Things Ahead.

Pryce Ancona (14:30): Cool Things Ahead, thank you. I was only at Epic for a year and a half. So Cool Things Ahead was led by someone new this year because Sumit’s gone. A little hotgossy, a little fun, a little spicy, but really, like everyone said, don’t overindex on it.

Brendan Keeler (14:48): You can index on it a little bit, in the sense that Seth Howard was one of the ones you would have rumored before. He was a known leader, on stage and doing stuff in different capacities. Before the big four were announced, he was in the running. He was on the Kalshi thing pretty high. Garrett was present, he presented internally a decent amount and did some public facing things. Lipsky is well known and a leader to the TS division or whatever. And Erv has been a public face in various capacities. But of those four, Seth is the person with the right Venn diagram overlap, that he would essentially be the choice. I think they’re trial running him a bit and seeing: does he have the charisma? Does he have the right leadership capabilities? That’s my guess, because the criticism Jodel has for him is that he doesn’t have that it factor. Judy’s got plenty of things you could say or not say about her, but she’s got her own personality and drive and charisma.

Pryce Ancona (15:46): “Charisma.”

Brendan Keeler (15:46): If charisma is a unique personality set, she’s got something. That might be why they’re seeing, does he instill faith in customers? Does he have the communication abilities to be doing Cool Things Ahead? There’s more credence to that than there was a couple of weeks ago, but I think they’re gonna try out leaders in different capacities and figure out a go-forward plan in the months to come.

Pryce Ancona (16:08): And credit to Seth Howard. From my perspective: Seth, you’re deciding if you want to lead Epic. You might not like it. Not everyone’s as crazy as Judy, so take your time, feel it out, hope you had fun at UGM, keep it up.

Brendan Keeler (16:22): Well, with that, we’re running low on this extra short emergency episode.

Brendan Keeler (16:26): We’ll see everyone for the FTC episode next week after that drops. Talk to y’all next week.

Ryan Brickner (16:31): Have a good weekend.

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 providing your payer so they can determine authorization, and then you submit the actual case. That’s framed in a way everyone can understand.

What people don’t understand is that each of those EHRs then has to figure out to whom am I connecting. Is it my top five payers, or am I going to connect to my clearinghouse and my clearinghouse is going to promise to facilitate the routing of this request to the right payer? Then it gets to the payer, and it’s a clearinghouse who maybe has never dealt with prior authorization exchange before, or never using FHIR and the DaVinci standard. They’re a layer that receives it and perhaps passes it to another system which does CRD, which might talk to another system which houses the questionnaires for DTR, which then might pass the case to a third system that’s one of ten utilization management delegated vendors at that payer.

It’s one of the first instances in a very long time in health tech where we’re saying everyone should start using this functionality on this date, and there’s a gajillion permutations of how and to whom you would connect. Any slight variability in how people interpret the specs, or let’s say one clearinghouse has a bug, and it’s going to be millions of prior authorizations that fail electronic transmission. And then what? So I’m concerned from an operational perspective. The tech will work itself out. What have you all been hearing from folks who are really in the prior auth weeds right now?

Brendan Keeler (08:31): I love Scott Rossignol’s idea, which he posted somewhere, or maybe it was Josh Mandel. Most people gravitate to this. Wait a minute, if we just had payers post all of their policy publicly, we could run an LLM over it and just have it. Instead DTR is here’s a little bite-sized chunk, oh, you want more, here’s a taste, here’s a little taste. That back and forth has a million rough edges that can break.

Even in the beautiful scenario where you take away the fact that the payer system is a million subsystems in a trench coat, pretend it’s just one system. Looking at the back and forth of client and server and server and client and subscriptions and CQL, it’s going to break. There are a hundred edges where it will break, and it’s just going to suck.

The idea of front loading it so you can shoot over the documentation you need, or making it a simpler transaction, makes a lot of sense. We’re not going to get that, but if you went back in time and reinvented this, that’s what you would do, MCG and InterQual be damned. That to me is logical. We don’t exist in that world. We exist in a world where there’s a million subsystems that haven’t really been accounted for and need to play in this space and meet the deadline.

Pryce Ancona (09:46): Just to be clear, some of the biggest players in the industry are saying, okay, we need to get this set up, let me see your specs. And whomever they’re talking to says, yeah, let me see your specs, let’s make sure our specs match. And neither side has specs and neither side has built it. Some payers are still figuring out who they’re going to use as the interop layer for their DaVinci implementation. This is supposed to turn on in what, four months. So it’s going to be a little heinous.

The biggest concern for me is that what could have been a jump from terrible administrative burden to computers doing what they’re good at and making everything more efficient instead becomes providers having a bad experience for three months and then using it as little as they’re allowed to by their employers or by the MIPS payments they’re receiving or not receiving.

Brad Thorson (10:37): Sometimes we flatten a workflow and its constraints and assume those constraints are directly related to motivations. Vectorizing a policy is creating an understanding of a snapshot in time. Payers have utilization management because they need to control spend. If there are easier ways to gamify that, they’re going to change the rules. This is a can of worms we maybe don’t have time to unpack today, but a major problem in assuming we can and should automate something is that we miss what the external friction is.

Brendan Keeler (11:13): No, I think you’re right. Great, we made the transaction cheap, but the tension of are you going to approve this or not doesn’t change. It’s just the speed at which that decision gets made.

The last thing that really grinds my gears about the situation we’ve put ourselves in is that HTI-4, buried in the IPPS inpatient rule last year, got rid of the light DTR option and really yoked this to the EHR. We’re in this era of we’ve got to empower alternative solutions and the EHRs are too powerful, and then we do regulation literally geared so that it must be in the EHR or in a supporting technology, where the EHR says okay, we’re using Darena as our chosen technology for prior authorizations. How can you go on stage and make these pronouncements and then get rid of the optionality for light DTR, which is more like launching a SMART app that does your prior authorization? Pryce, do you agree? You were working on this.

Pryce Ancona (12:10): One hundred percent. To explain the paradigm for the audience: let’s say I’m a doctor and I place an order for an MRI. I should get an immediate response, if the back end systems are set up and connected, that says hey, you do need to request prior authorization for this order, and here are the questions the payer has in order to determine whether they’re going to authorize it. Those questions come across in the form of a FHIR questionnaire.

At the moment, the EHR must support receiving those questions and showing them to the user, and the user answers them in the EHR. That’s called the native flow, where the provider stays native to the EHR. But there are vendors who do way cooler stuff with clinical data that helps you answer the questions way faster, and that could be a SMART app.

Let’s say I place that same MRI order and boom, because my analysts set it up this way, instead of the questionnaire coming back into the EHR it automatically pops open a SMART app window with my questionnaire app. There’s a field in that one that says just drop all the documentation about Brendan and I’ll run AI through it and propose answers for you. I’m like, gosh damn, that’s so cool. That’s what generative AI should be doing.

Somebody’s out there building it because all they care about is prior auth. Meanwhile the EHRs are getting the regulatory capture and aren’t forced to support that bolt-on system, which is the light DTR flow. So that’s the difference between native and light DTR. It’s a silly nuance and I guess just a bunch of nerds care about it, but in a year a bunch of providers are going to care about it.

Brendan Keeler (13:43): We are those nerds.

Ryan Tucker (13:44): Us.

Pryce Ancona (13:46): So I’m bummed about that. But folks smarter than I wrote those rules, so we’ll see where they go.

Ryan Tucker (13:52): I’m curious here, and we’re going to get into new regulation coming, HTI-5 and HTI-6, in more detail. Taking the lens of HTI-5 coming in, it was very deregulatory. It was trying to strip out the old news, the things that didn’t matter anymore. HTI-6 is now rebuilding that with more FHIR-based standards.

But from what you’re saying about how 0057 is looking, we don’t know what’s going to happen once January first hits, and the signals aren’t great. It seems like the IGs might be a little too broad, or at least we don’t understand what’s going to happen behind the scenes once the message gets there. What could have been better for 0057? Was it stricter regulation? It seems like we’re not moving that way. Is it not building in the how, and instead focusing on the actual why behind the workflow? I don’t really know the answer, because maybe it’s you just need to meet this end goal and you can accomplish it how you want, but then that’s very broad and everybody will have a different interpretation and it’ll be hard to play together. Pryce, with that lens, do you think there’s anything that could have made 0057 better as we get to this point of what looks like it’ll be chaos?

Pryce Ancona (15:16): Yeah, it would have been great if in the rule they mandated everyone use HTD consulting for the services they need. I’m just kidding.

Brendan Keeler (15:25): We offer prior authorization services.

Pryce Ancona (15:30): This next segment brought to you by. It’s hard to say, because the problem to be solved is part of the issue, Ryan, not the regulation or how they wrote it. Like Brendan said, take a bunch of different software systems who have never had to do challenging interop before. Maybe they’re all even small, because none of them are gigantic core administrative processing systems like TriZetto or gigantic EHRs like Epic. You’ve got all these green newbies going, I think we’re supposed to do something for CMS by January first. And then you gave them the hardest IG of all time to implement, hands down.

So maybe it shouldn’t have been a boil the ocean approach. Maybe we should have started with CRD. Get your most health tech eager analyst to set up clinical decision support with regards to coverage requirement discovery. Then you submit, and you get to submit sixty percent of the prior auths you usually submit, because for forty percent of them you realize you don’t even need prior auth. Maybe what we needed was a little bit of stair stepping.

But this whole administration, and this is what I was thinking while you were talking about the Health Tech Ecosystem, Brad, is throwing spaghetti at the wall to see what sticks. They’re going to see who succeeds and who survives, and then they’ll regulate, or there will be carrots and sticks they create in reaction to how the market adjusts. It’s a little bit ruthless. We just got thrown into the water by our belt loops and we’re going to figure it out.

Brendan Keeler (16:59): All right, Tom Sawyer. And look, I appreciate the focus on the workflow. It’s just that the shape of it is contorted by these weird oddities we have in the industry, like MCG and InterQual not wanting to give up their policy because it’s their IP and their business. I don’t blame them for that. That is how they make money, but it contorts a lot of this into a less useful shape than if we’d thought about it de novo.

What else are we thinking about for the rest of the curriculum this fall? What take home tests are coming? What books are we reading?

Pryce Ancona (17:36): I don’t know, you tell us. You’re the TA. I’m forgetting. We have HTI-5 finalizing, and then Ryan was just saying we have a proposed HTI-6. When is the comment period over, or when does that finalize?

Ryan Tucker (17:51): Is that toward November?

Brendan Keeler (17:52): We know from the unified agenda that HTI-5 will be this month, that they’re trying to finalize in August. That’s the deregulatory rule where they deregulate away parts of information blocking in a way EHRs aren’t super psyched about. And then HTI-6, which we don’t know what’s in it. It’ll come out in November or something like that, but should have a lot of new API stuff, is what they’ve hinted.

Federal lawsuit against Epic rumored to be coming. We don’t know what that’s about, but we shall see. And then of course the test on January first with prior authorization. Lots of fun stuff. What do you all want to see in HTI-6?

Ryan Tucker (18:30): Lately I’ve been thinking a lot about agentic movement with AI. Brendan, what you brought up in terms of publish your spec out there and let an agent cater the transaction building and message building to what needs to happen, I think that would be really interesting. I know some of that was covered in HTI-5, there was some around agentic execution. But more FHIR-forward standards in general moving forward. That would be interesting to me.

Pryce Ancona (19:00): FHIR subscriptions is what I’m most interested in, by a pretty long shot. But the subscriptions work group in the CMS Health Tech Ecosystem is just encounters and appointments. Encounters and appointments is a little bit too small for me to start jumping up and down for. Having an API you can subscribe to for proactive event notification is the most insane thing we haven’t regulated yet.

Brendan Keeler (19:27): You make a really good point. There are many ways for ONC to F this up in HTI-6, so commentary will be important. One you just highlighted is whether there are the right triggers and data types. Subscriptions is really broad and can be used for a lot of different things. If they just have it for encounters, is it sending every new update, or just on certain triggers? Those details will matter in accomplishing a goal.

I wrote an article a couple weeks ago about this. If they just look at Argonaut’s work and adopt the patient subscription, which is an IG that profiles subscriptions to accomplish a workflow, you could easily say all right, Argonaut never misses, let’s just copy that. They did great work focused around I am a patient app, or I have a single patient and I want to listen to updates to that patient. That’s supplementation. That’s not enrollment.

What people yearn for is not better supplementation. Better ingestion of a patient once you know about them as relevant to you is great, hurrah. What we want is the ability to kick off a workflow, because we can’t poll right now. We can’t search across and say show me all new orders. We can’t listen and say show me all new orders, or let me listen for new encounters. Enrollment is the big unsolved problem that prevents ninety-nine percent of apps from being FHIR native. We need to make sure that’s in HTI-6, or we’re going to look up and go great, now we have slightly better supplementation and I still have to start with HL7v2 as my enrollment step.

Ryan Tucker (20:59): So you’re calling for the death of ADTs?

Brendan Keeler (21:01): Look, if we want to live in a world where it’s FHIR only, we’d need to go after enrollment. You can’t reliably assume an EHR has HL7v2 ADTs. From certification criteria alone, you don’t get a uniform enrollment step. There is no technology.

Brad Thorson (21:18): Wait, but I have a prediction.

Brendan Keeler (21:19): What’s that?

Brad Thorson (21:20): What I’ve been doing while you’ve heard my keyboard typing: if you take a look at the health tech ecosystem, actually there are very clear motivations, things certain people in power want to see. We’ve also seen a ton of CMS programs launched, and it feels like it’s at a rapid pace. So I was trying to figure out what is the intersection of BALANCE, TEMPO, ACCESS, and ELEVATE. This group is smart enough to know they can use HTI-6 to unlock that. I’m mid research, mid-pod, so I’ll get you a better explanation after I can think about it more.

Brendan Keeler (21:57): I’m like, man, is he writing us a SOW right now for a prior authorization deal for the payers and delegated vendors we help?

Brad Thorson (22:06): I do think connectivity to TEFCA or these nationwide networks, as opposed to directly into the EHR, is it. There’s going to be something around network access and whether that ropes in HIEs or the new state based HINs, or whether it’s all at the national level.

I would not be surprised if there was some effort for regulated devices to have connectivity, whether that’s cellular built in. There’s no way CMS is going to pay for GLP-1s and not try to track things like blood pressure and weight, which fits into the ACCESS model.

My wild, out there hypothesis, based on three minutes of Googling and writing, is that we’re going to see devices that wouldn’t normally have fallen under certified health IT somehow get roped in positively. Give them an incentive: hey, if you add cellular connectivity to your blood pressure cuff, we know that’s going to get us better readings, and maybe it ships pre-integrated with TEFCA and we’ll increase your reimbursement by fifty cents a reading. HTI-6 and the payment models are not connected, but I think we’re going to see something.

Brendan Keeler (23:20): We like those intersects. That’s good. All right, FMK. We’ve got FHIR subscriptions, bulk FHIR, and agentic access. Which are you feeling for HTI-6 in regard to those three technologies? Which ones would you keep or cut?

Pryce Ancona (23:43): Agentic access in what form here? Are we saying it’s information blocking for EHRs to not allow agentic access, which is already true, or are you saying something else?

Brendan Keeler (23:54): We don’t know. They’ve alluded to MCP or COIN as the technology some people have started to play with in the healthcare setting, conversational interop, or just allowing screen scraping. Who knows. HTI-5 said the information blocking stuff as proposed, where agentic access can be EHI exchange. HTI-6 would be some sort of certification requirement. So we don’t know the shape of it, but you get to choose a little bit.

Pryce Ancona (24:22): Okay, well if this is a which would you rather, I definitely have my answer. But does anybody else want to go first? Brad?

Brad Thorson (24:28): I’m ready. Ryan, are you ready?

Ryan Tucker (24:30): I’m ready.

Brad Thorson (24:31): All right. The most clear one for me, so I’m not going to go in order, but I’m entering matrimony with FHIR subscriptions. We need better signaling, and this brings our data model forward multiple decades. That’s the one we want to be with for a long time. If you disagree with me, you’re wrong.

The complicated part is the other two, and I’ve got to say, I’m sorry, bulk FHIR, but you’ve got to go.

Brendan Keeler (24:57): Aneesh Chopra is sad as he listens to this.

Brad Thorson (25:00): Maybe not. If we’ve got agents that are able to vectorize that data, it doesn’t matter what format it’s in. Could we not just do a giant data dump into whatever your data model is and do some probabilistic estimation of I think this is an HbA1c number? If this is our decision set, then unfortunately, bulk FHIR, you are the weakest link.

Brendan Keeler (25:21): Ryan, what do you got?

Ryan Tucker (25:22): Maybe I’m going to cheat the game a little bit here, but I’m going similarly to Brad in my F. From Brendan’s description, agentic usage is a little flirty. You don’t know what it’s going to be, and frankly the next day you don’t know if you’re going to call it back. We’ll see what happens there. That would be my F.

Marriage, I’m going to say bulk transactions. Usage for population, like can I actually set up my day for my whole organization. I’m not going to say bulk FHIR, because if we’re saying marriage, yeah, FHIR’s been around a while, but we’ve seen many. We’ve seen HL7 v2, v3, v4. I don’t know if FHIR is going to be around when I’m ninety. So bulk transactions is what I’m more interested in for marriage and seeing where that goes.

And then I guess I’ve got to kill subscriptions, even though in the near term that’s probably what I want. I’d like to date subscriptions right now if I could, but I think that’s outside the rules of the game. So I’ll stop there.

Brad Thorson (26:29): You’re wrong.

Brendan Keeler (26:30): Pryce, what are we thinking?

Pryce Ancona (26:32): What do I want the most? For sure subscriptions. Brendan, to your point, we’ve got these nearly ubiquitous nationwide networks and they’re query only. Everyone has to make a FHIR API available, query only. How is a new clinic going to hear about a patient? How is a new telehealth app going to hear about a patient? How is the remote patient monitoring cardiology program going to hear about a patient? It’s always an event triggered subscription, or an HL7 ADT, SIU, ORM. Those have been tried and true for us for longer than we’ve been alive. At least most of us. And sorry to the analysts listening who are like, I was implementing ADT in 1989.

It’s time we have something in place that EHRs are forced to support, so that information blocking matters. If you can’t even figure out which patients you’re supposed to treat and why and when, then you have half the companies I know that do cool work running off manually copied Reporting Workbench reports to figure out who they should be treating. That’s just insane to me.

So I’d want subscriptions to include upcoming encounters, encounters, registration, discharge, appointments, but also orders. If we don’t get orders, then I’m going to be like, what the hell is all this for?

I don’t really like AI right now, just in general. Lots of mixed feelings. I saw some robots fighting today on LinkedIn and I was like, I don’t like that at all. So I’m going with bulk FHIR for number two. I also think it’s a nice stepping stone for all of these developers. Hey, now you could offer something that’s like a SQL search but for other people. You can understand that. That would be nice.

And if we ask them all to implement MCP and we expect it to be as good as Databricks natural language queries, it’s just not. It’s going to be garbage. So I’m ready to stay away from the agency stuff for another couple of years.

Brendan Keeler (28:26): I’m going to bend the rules too. I’m going to do a thruple with bulk FHIR and subscriptions. Let’s see the FHIR stuff through. Let’s see if this solves everything. Then we’re going to have to kill agents, because I don’t need Dario Amodei to get any more of my money. We don’t need data centers and we’re not ready.

It’s where we started. We’re asking, well, what are we going to require? If we’re asking that, we’re probably not ready to put in requirements if we don’t know whether it’s MCP or what. So I think there’s potential for HTI-7 or 12 or something, but for now, burial for agents.

With that, we’re at time. Thank you all. We’ll see you on the next one.

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 feedback app you found? Jodel. We gotta go check Jodel for additional intel.

Brendan Keeler (04:45): For those who missed it, Jodel is a social networking app used by Saudi Arabia, by West Point, by a number of German college towns. It’s anonymous in nature. It’s public, you’re not posting in a private group, but it is anonymous, so you see it in areas where the identity behind social media posts could be used against you. Saudi Arabia, where it could be used against you by a slightly oppressive government at times. West Point, where deviating from the expected code of conduct could be extremely impactful. And Epic, where social media is largely banned. So it is certainly a place of commentary on anything that happens in the Epicverse.

Bryan Fowler (05:25): And the source of some bigger news, right? That’s how we found out about Claude being introduced internally at Epic, among other things. Definitely not a traditional news source, but a really easy way to get to the ground-level details of what people are talking about at Epic.

Brendan Keeler (05:40): And they are talking about it. Many posit what you mentioned, Brad. Look, the stock went up thirty-three percent in February, on top of other gains. They are bucking the system-of-record trend, where by and large the rise of AI has really hurt Salesforce, has really hurt ServiceNow, has really hurt most public and private valuations of systems of record, because the market views AI as being able to crack them open and steal a lot of the value. We’ve talked before about whether that’s warranted, but that’s what’s being reflected in the market to date. And yet, at least according to Jodel and other sources, Epic stock trends up at such a rate that people there three or five years are getting six figures, seven figures. So you imagine what Sumit must be banking given his long tenure. It’s not unreasonable to say: let me go take care of my mother, let me go buy the lake house, the private jet, the whole shebang.

Brad Thorson (06:31): The other thing you alluded to, and we’re certainly making no predictions: has the OIG indicated interest in information blocking toward one of the big E’s? Whether or not it’s Epic, and whether or not somebody ends up winning or losing, that’s just a lot of stress for something you’re not interested in, that’s really orthogonal to day-to-day concerns. Maybe that’s a younger man’s game. A very, very young man’s game.

Brendan Keeler (07:01): Yeah, he’s already deposed in Texas, right? He’s deposed in Particle and some of these others. Senior leaders, by and large, there are protections you can have in court against frivolous waste of their time, but you can assume he’s pretty busy with that. And as soon as a DOJ, FTC, ONC case kicks off against them, you assume he’s going to be on the stand. If you’re a technologist, you’re like, I just want to go make AI s**t. I don’t want to be in lawsuits. So that could certainly be part of the mix.

Bryan Fowler (07:37): There’s an assumed responsibility if he remains at Epic. Even if he’s not as active in his traditional duties, I’d assume he gets pulled in all sorts of ways.

Brendan Keeler (07:46): So the last factor. The pull being AI, the non-pull being some of the money and the court cases changing the dynamics of the position. The push could be a coup, could be politics, could be internal drama. There’s not strong evidence of that, but there have been rumors of that before, with Carl Dvorak allegedly being pushed out a few years before some other incidents. So the rumor mill continues to turn. That’s only really validated by departures of other senior leaders. And that could happen even without internal drama, because that’s just what happens when leadership changes. If you’ve yoked your wagon to Sumit, and suddenly someone junior to you leaps you, or someone you don’t like is a potential leader, well, you might consider a move, or consider retirement yourself.

Brad Thorson (08:38): Two things on that. One, for the screenwriters trying to pitch HBO: we would love to work on the show. Keep us in mind.

Brendan Keeler (08:45): It’s Netflix now, right? Well, do you think Larry Ellison’s company is gonna do it? Maybe, actually.

Brad Thorson (08:52): Yeah, they want to make him look terrible! It’s gonna be spicy.

Bryan Fowler (08:56): Game of Thrones, Epic edition.

Brad Thorson (08:59): Okay. But so I was misinformed. Who’s gonna be next? There’s four? A quadfecta? Is that what we’re looking at?

Brendan Keeler (09:09): There’s a Latin term. Like a triumvirate, it’s a quadrumvirate. There were a number of Kalshi potential leaders here, engineers like Seth Hain, their AI lead, Seth Howard, a longtime leader, Stirling Martin, a longtime leader. Bryan, are these names familiar to you?

Bryan Fowler (09:29): Definitely. Folks that have been prominent at UGM, done presentations, at least when I was there, on more siloed features, like AI and Cool Stuff Ahead, but also traditionally with software development backgrounds.

Brendan Keeler (09:44): A lot of people are naming them. And Seth Hain has been very public, in a way beyond how Sumit has been public. Sumit’s public the way Judy was public: known to customers, presenting at UGM. He does some public-facing stuff, but if you search YouTube, there aren’t tons of videos and interviews of him. The past couple of years, Epic has had leaders who project into the market. It’s a new trend for them, maybe the last five years, since they got a new marketing lead. Seth Hain is this AI nebula lead, and he definitely has personality and some charisma, the nerdy engineer charisma. He’s on stage at Microsoft and Anthropic. They have Jackie Gerhart, CMO or some high-level medical position, tons of charisma, great at presenting, very public facing. And then they have winners, I would call them. People who have been thrown at things internally at Epic and continually won.

Bryan Fowler (10:50): I was gonna say, the Alans, the Fritz. So with Alan Hutchinson, someone who’s been very prominent in some of the major fast-turnaround wins for Epic with Payer Platform, and a really vocal advocate in the new growth space. And Fritz, maybe you take a hit at Fritz, because I’m less familiar with him.

Brendan Keeler (11:13): You can’t even really find him, but when I was in the Netherlands, he was the lead of the Epic Den Bosch office and sort of turned it around. He turned Home Health around into what’s now Dorothy. He launched some level of the services stuff they have out there, I think Boost, maybe all of it. And now he and Lars are both high level in terms of implementation. So, proven winner. Like you said, Alan Hutchinson, many people mentioned him because Community Connect is one of the biggest things for Epic, extending down market, and then Epic Payer Platform and these other initiatives have been varying levels of high success. There’s winners like that. But there’s a big “but” for all of them. Can you guess what that is?

Bryan Fowler (11:54): They’re not developers by background. Which is a very clearly stated goal of Judy’s succession plan.

Brendan Keeler (11:56): They’re not developers. So the thought was, okay, if we’re gonna get a Jackie or a Fritz or an Alan, it’d be a real about-face on some stated things. Could that happen? And the answer, at least for right now, seems to be no. Because in the follow-up to Sumit’s email last Friday was an email from Judy a day or two ago that said there’s a chosen group of leaders that will be rising to take on the various responsibilities of Sumit. And one of them is one of those market leaders. We have Seth Howard, who was seen as a potential leader and is indeed one of these people named by Judy. We have Erv Walter, a longtime developer, well known, been around, visible. He has a very poignant story about his own heart transplant that you can see on Epic’s site (we’re not exposing PHI here). He’s also known for being the face of Epic’s ill-fated return-to-work initiative in 2020, where they were trying to get everyone back by August 2020, a little earlier than many other corporations. Let’s see, who are the other two?

Bryan Fowler (13:09): Another surprise one I saw on Kalshi was Sam Petermann, who I believe heads or headed Epic Corps, Epic’s international arm of technical services and implementation teams.

Brendan Keeler (13:21): That was on Kalshi, but he was not one of the anointed ones. At a certain point people were just naming people to add them to the discourse, and I think that was one of them. But we had Mark Lipsky, another software development leader. Did you know him?

Bryan Fowler (13:40): Rev Cycle lead for the R&D team for a good portion of my time there.

Brendan Keeler (13:47): He’s getting rave reviews internally, from the Jodels and the Reddits. He’s not as public as Seth or Erv.

Bryan Fowler (13:56): Very engaged with customer escalations, customer relationship management when it comes to Rev Cycle. And as we see things moving down market, moving beyond just the clinical point of care, Rev Cycle is a huge product space for Epic. So that could make sense as well.

Brendan Keeler (14:13): Totally. And the last one is almost of the Sam Petermann vibe: Garrett Adams. This one I just didn’t know. He was a dark horse pick. People did mention him in various Slack groups and WhatsApp and LinkedIn, and I thought, okay, they’re just tossing him in there. But he leads, or led, the EpicCare Ambulatory R&D division. He’s young compared to some of these other names. Everyone else started around 1990, maybe late forties, early fifties. Garrett maybe started two years before I did, 2010 or so. And yet he’s joining this council, this quadrumvirate. He’s been the public face for Art, their AI product. He’s probably the interesting wild card in it all.

Brad Thorson (14:58): The real long-term bet on Kalshi is that Sumit is actually taking a leave of absence to figure out how to upload Judy’s consciousness to an AI so she can rule Epic forever.

Brendan Keeler (15:10): Mother looks over all of us. This leadership council could be a race, right? Who shall win, who shall prove themselves? It could be to groom a specific CEO out of that crew, maybe Lipsky or Garrett is someone they need to mature into the position and make sure customers are comfortable with. Or it could just be a temporary measure, because Judy is still very much here, still very much with it, still very much a leader driving Epic. So, more to come. We shall see, especially as we head toward UGM, Epic’s User Group Meeting, next month, and watch for any other exits from upper management in the weeks or months to come. But shifting gears: what else did you read this week?

Bryan Fowler (15:52): I have one. Don Rucker, one of our good friends, the previous National Coordinator at the ONC, involved with a number of high-profile regulation updates, was recently on one of our friends’ podcasts talking about patient matching and whether it’s a problem for interoperability. One of the things Don was saying: a patient walks in, they verify their identity, they’re usually going through an eligibility check before they’re ever on the schedule or seen by a provider, and the payer involved in that visit, all of those users, have very good information about who the patient is. Patient matching isn’t as big an issue as it may seem to the broader community. I think it’s a good point, but I also wonder how much it misses broader longitudinal care. So where’s the mismatch? Why are we hearing patient matching is a problem, it’s not a problem, what’s going on?

Brendan Keeler (16:49): The success of patient matching for those flows, for eligibility, for the clearinghouse flows, is predicated on a shared patient identifier: the member ID. So if we strip out the nuances of everything, why aren’t we driving toward that? Of course a shared patient ID would improve matching rates. And you see that actually playing out. In the CMS Health Tech Ecosystem, there’s a big dialogue, a big push, and a big fight really, about CLEAR and ID.me issuing a patient identifier so it can be a deterministic link. There’s a huge fight over SSN and its validity and usefulness as a shared patient identifier, with some proponents saying, well, if we have it, we should use it, and others saying there are security or privacy problems with it. We live in a world where many scenarios, as you’re saying, don’t have that: don’t have the chance to collect a social security number, be issued the deterministic ID from CLEAR or ID.me, or otherwise have a shared patient identifier. Congress has had trouble for decades getting their s**t together on a national patient identifier. But that’s a possible piece of the solve in the equation.

Bryan Fowler (18:00): We’ve seen it play out in other countries, where a national healthcare identifier is used to connect systems of record to each other. You mentioned there’s been sensitivity with those identifiers in the US, reusing a semi-financial or security-related number for healthcare purposes. Does everyone need access to that full identifier? Is there a risk of sharing it too broadly? What gets to me is not just whether we can make a single deterministic link in an acute instance, but how we’re addressing the overall problem across many different sources that have useful reasons for being involved in the provisioning of healthcare, the payment, all those things. There are more issues than just: is the Brendan who walked in front of me actually Brendan, and can I submit a claim and get reimbursed for the care I’m giving Brendan? Versus, once I pull Brendan up in my EHR, do I have everything I need to know about Brendan to provide valuable care that day? Connecting care gaps, connecting your urgent care visits from the last few months to make sure there isn’t something we should follow up on. All of those require more than a single point of identity verification. It’s connecting the whole system in a way that all players, regardless of whether their individual use case justifies access to a sensitive identifier, can still communicate productively and give providers what they need to give the best care.

Brad Thorson (19:34): Bryan, you and I have talked about this before. When I was a younger man and liked to mess around with various technologies, I ended up with tons of email addresses, multiple Google phone numbers. I use Brad and Bradley intermittently across all these systems. I am an Aetna member who also uses the CVS app, and I have two different CVS rewards accounts under two different numbers. Try as I might, sitting on the phone, I’ve never been able to get them to merge those accounts. Which is great, because my coupons don’t add up quickly enough. And I know that problem exists on the health record side. But alternatively: having systems that don’t overlap one-to-one is also a form of fraud prevention. Part of me worries, and I’m not educated enough to make a definitive comment, but given the way we pay for care, that we don’t have an MPI across every payer, and every payer’s internal systems are different, I feel like we’re introducing a potentially huge risk of system abuse by people who understand how to use a patient identifier very quickly and get out. We see it in Medicare fraud all the time. Does this not increase the risk? And maybe that risk is fine, maybe the instances of failures of care or misbilling are so much larger than the potential downsides. I don’t know if either of you have opinions on that particular double-edged sword. Brendan just licked his lips, so I just opened a can of worms.

Brendan Keeler (21:14): One, to Bryan’s earlier point, international countries have figured this out. Let me cook. The Netherlands has the BSN, the burger social number, which is the tastiest patient identifier you could imagine. When you do anything to really interact with the system, you do a BSN check against the government registry, it strongly gives you back that burger social number, and it’s then used for almost every transaction. There are edge cases where it’s unavailable, but they’re just a pain in the ass. Once you’ve built the contained system of strong identity checks on the edges, suddenly everything works a little more seamlessly and you have that identifier. I’m excited because, sans Congress or other top-down regulation saying “we must create that perimeter,” forces are making it happen via this digital identity wave. You see CLEAR and ID.me and Persona being inserted via the TEFCA Individual Access Services apps. You see CLEAR and ID.me starting to be inserted at MyChart and patient portal edges, and at employee edges. There’s certainly identity proofing for prescription of controlled substances. The more we build strong identity checking, well, by default we get the deterministic identifiers. There are still problems, like what if I’ve done ID.me before and then do CLEAR for another one: interoperability of the CSPs. But it’s better, and you get cleaner demographics, which allow for cleaner matching. So I think that’s a big force for good. The caveat being that there’s a strong vocal minority in the US that views digital identity the same way they view vaccines or microchips, put it under your skin. So there is certainly pushback to this force for good that digital identity is offering.

Bryan Fowler (23:12): Responding to something you said earlier, Brad, about whether this introduces risk of fraud: my counterpoint would be, maybe we’re reducing the risk of over-ordering. We don’t get duplicative procedures, duplicative labs, because we’re able to see that Brendan just had a CBC last week, maybe I don’t need to order that again. Those would also go down. So we have to look at it on all sides. Are there meaningful use cases for the exchange of data? Surely there are. And how do we make that accessible to players in the system who aren’t necessarily the system of record but are engaged in improving healthcare, lowering costs, providing better outcomes for patients?

Brendan Keeler (23:52): And fraud takes many flavors. There’s financial fraud, and the government’s prerogative is, let’s stamp out financial fraud, the defrauding of the US government, because that’s wasteful spend and should be given back to taxpayers. At the same time, on defrauding patients, taking clinical data and selling it and things like that, we have an increased permissiveness for data access, where we’re willing to accept higher levels of that latter type of fraud at the same time that we’re really clamping down on the former. That distinction is worth delineating, because there are incredibly divergent perspectives going on right now as we really stop one and really start to allow the other. False positives and false negatives.

Speaking of the government, we had some cool stuff happen this week. The Unified Agenda, after a long pause, came out of the woodwork. It’s been a semi-annual plan since the Clinton era, where the different agencies say what they’re gonna do. Do they do what they say? Not always. But it gives some perspective from the Office of Management and Budget on what’s going on across agencies and which month they’re gonna get certain things done. And we saw some tidbits in there.

Bryan Fowler (25:03): They say it’s a semi-annual report, but how has that actually played out in recent years?

Brendan Keeler (25:09): We’ve seen slippage, continued slippage, administration after administration. Supposed to be in April, it’s in July. Supposed to be in September, it’s in October or November. I did a post a while back showing how it just slipped and slipped across administrations. We’ve had a reset once before, in the Obama era, where Obama said, all right, we missed this one. People say it’s because midterms were coming up and they wanted to do their initiatives after midterms. Some truth to that potentially, because then they were pretty on time again for the next couple. But this one was way overdue. The last one we saw was spring 2025. No fall 2025, no spring 2026, we’re almost in fall 2026, and they did a single airdrop branded only as the 2026 Unified Agenda. But we’re excited. We love regulation. We love deregulation. We love everything our government regulators do. That’s not true. But we appreciate the drama and the excitement of them making moves and the effects on the industry. And we saw a date for HTI-5, the rule proposed early this year, in February or so: potentially finalized next month. Are we ready?

Bryan Fowler (26:24): More than anything, these drops give us common vocabulary. As we’re talking with other folks in the community, with health systems, it’s like, okay, this new feature sounds great, but how do we actually get someone to buy in on an implementation, on development? Being able to point to something and say, this is real, it’s potentially finalized on a certain date, this is what we can expect, that at least starts a conversation. For a very long time, things like HIPAA, how many people have misquoted HIPAA and said I can’t talk about this or do XYZ because of HIPAA? It takes going through this process of getting drafts out, getting approved, talking through the concepts, so we can land on what this actually means for developers, for providers, for anyone looking at taking advantage of new features. There’s so much hesitation in this space around sensitive information and security concerns that it really takes a solid definition for people to latch on and get things moving.

Brad Thorson (27:33): Generally, frequency of comment or activity shows intention or interest, and that drives private actors to start taking something seriously. I don’t know that ONC-certified products have taken their initial attestations overly seriously for many years. Now they seem to be making really good-faith efforts at meeting standards deadlines, and that can’t be divorced from the increased publishing activity of the former ASTP, now ONC. So even if the regulations or the intentions aren’t always things I would push for, the publishing certainly spurs the large actors in the space to be compliant, participatory, et cetera.

Brendan Keeler (28:27): Hearkening back to one of our earlier conversations this episode, we did see a rule in the Unified Agenda related to identity. Maple syrup identity, from the FDA. I was scanning through and thought, my god, an identity rule from an HHS org, and then it was maple syrup identity, making sure the provenance says the maple syrup is appropriate.

Brad Thorson (28:47): Grade A, grade B.

Brendan Keeler (28:50): How do we reconcile and have interoperability for Aunt Jemima’s and other flavors? But we had HTI-5 and HTI-6 both listed in there. We get HTI-5 first. Not much new except a date of August, but it has the EHR Association spooked. The EHRA did a post about it. The comment period was ages ago; the comments are shipped, they’re public, we’ve reviewed them, we’ve read them. But all of a sudden the EHRA posted on their blog saying, we have a series of posts, this is the first, analyzing the HTI-5 proposed rule and the complexity it adds rather than reduces. It sounds like they’re spooked by this rule, which hypothetically was a deregulatory rule for their benefit. And yet, as we’ve said before, it’s pretty obviously not, because the information blocking changes they propose are quite burdensome to EHRs. The EHRA is not shy about saying the 10-business-day response window is unworkable, that defining fair market rates is gonna force a ton of formal valuations that will be costly for every product and every integration, that there are contradictions between the contract-of-adhesion language and the ONC’s own requirement to publish standardized API terms. These are all fair critiques that hopefully were in their comment, because that’s the right way to do it. So why do this blog post? It’s to signal: as you finalize, you may consider that there could be legal challenges. That’s often a strategy of these associations. Notably, they say there are missing burden estimates. That this deregulatory rule could actually not be deregulatory, and they failed to do burden estimates, which they’re required to do. To me that signals: you push something crazy out the door, we’re gonna push back on procedural grounds. And in a deregulatory environment, on paper this administration is deregulatory, well, suddenly that turns the watchful eye of Sauron upon regulators who are regulating through deregulation. That would be a big no-no and could cause some heads to roll. That’s a fun dramatic twist.

Brendan Keeler (30:57): And then this fall we get the big finale. Well, at least the next sequel in a series that’s competitive with Moana in terms of frequency. The HTI series is gonna drop a proposed rule, hypothetically November, and it looks to be a lot of fun.

Brad Thorson (31:12): You can clearly tell Brendan is the father of small children with the Moana reference.

Brendan Keeler (31:18): I just can’t believe they did one... Moana 2 was last year and now they have Dwayne The Rock Johnson in a live-action one. Come on now.

Brad Thorson (31:26): Moana 2 was supposed to be a TV show that they decided to push into theaters to help save Disney’s cinema business.

Brendan Keeler (31:35): Do you have kids, or are you a cinephile?

Brad Thorson (31:37): Just a cinephile. Most people don’t know this, but I used to run a movie ticket website, so I still follow trade blogs on the topic. Anyway. One not my child, an adoptive child I gave up for foster care. Bringing it back: FHIR subscriptions have been something the community’s been talking about for a really long time, and we know some EHRs have been working on them, potentially looking to introduce them. Seeing that as a component of future certified IT software is pretty exciting, and honestly potentially eroding some of our business, because one of the hardest things for many applications is figuring out whether they should do something. Oftentimes it’s an HL7 message, which requires having a VPC if it’s a hosted EHR. It’s not a novel pattern, it just takes a lot of work. The rest of software has moved on to patterns like webhooks to indicate to third-party applications there’s been a change of state, you should look into it, using the same authentication pattern. From an ease-of-developing-applications standpoint, in combination with information blocking, where there need to be interfaces to read and write, this is potentially monumental. We’ll probably get a certification date of 1/1/2032. But very, very excited.

Bryan Fowler (33:09): It gives us that framework of: if you attest to being certified, meeting that criteria, then other folks trying to integrate with you, if they find that not to be true, well, you have to defend yourself or face the risk of litigation. Having that path lets us iterate and improve, whereas leaving it up to the vendors, we might not see those things happen.

Brendan Keeler (33:31): For people who haven’t followed the old episodes: subscriptions is the big one, and we expect API-forward certification criteria in addition. CDS Hooks, maybe SMART Health Cards or Links, maybe some FHIR write. Argonaut has done work on writing some data back to the EHR.

Bryan Fowler (33:53): Or time-based access tokens.

Brad Thorson (33:53): Or dereg around APIs. Having certification criteria move to programmatic interfaces versus visual interfaces, making it easier for an entity to prove they can in fact provide a certain amount of data or drive toward certain outcomes, and in doing so having to expose the interface a third party would integrate with. A lot of attestations today, like “are you driving toward better prescriptions,” aren’t using deterministic testing. HTI-6 is theoretically gonna move us in that direction, which is also exciting.

Brendan Keeler (34:30): Picking up what you’re putting down: the dereg via HTI-5 got rid of a lot of the UI components. Some are statutorily required to be in the criteria, but HTI-6 could API-ify them. It would be pretty exciting if they chose to pursue that and further remove the user interface considerations tightly bound into the criteria. I do think subscriptions is the most exciting piece. If you’re a patient app, great, you can get more data without polling all the time. If you’re an analytics app, you can do your bulk pull and stay up to date with subscriptions. Those are nice additive things, but patient apps and analytics apps are pretty well served by the regs today. It’s the provider solutions, those point solutions, the wide host of scribes and HCC coding apps and lab information systems, everything that sits ancillary to the EHR in the ecosystem, that have been underserved by the regs. FHIR’s been nice for pulling additional information if you know a patient, but not for knowing which patients are relevant to you. Enrollment of the patients, the relevant population, to your application. Subscriptions are such a nice way to accomplish that, if the regs actually focus on it. And it’s a big if, because our good friends at Argonaut, who have done all the work on all the great things of FHIR, on bulk, on the base REST API, on the FHIR write stuff, did a FHIR subscriptions implementation guide, the Patient Data Feed, which uses subscriptions but isn’t focused on the enrollment events. It’s focused on: was a note created, was a lab resulted, was a vital put in. Those are great things, but typically those aren’t the most common enrollment events. It’s: was a patient created, was an encounter started, was an appointment scheduled, was an order placed. Those are the big four I can think of. Bryan, any other good enrollment mechanisms come to mind?

Bryan Fowler (36:27): Changing plans. Any kind of coverage or billing-related updates. That’s one of the bigger ones that comes to my mind.

Brendan Keeler (36:35): That’s a great point, and I didn’t think of that one. I didn’t care about you when you were on Aetna; now you’re on a value-based care plan, and my app does care about you. Certainly a potential enrollment trigger. Well, we didn’t focus on that. We focused on supplementation, making supplementation easier. We’re going from FHIR that works pretty well to FHIR that works really excellent, rather than saying: we don’t have a standardized capability for enrollment, let’s get one. So I hope our regulators are prudent enough and thoughtful enough in this HTI-6 rule to propose it. Because if not, we’re gonna comment pretty vocally. But with that, we’re running out of time for the day. Thanks to the audience, hope to see you soon. Thank you, Bryan.

Brad Thorson (37:15): See y’all.

Bryan Fowler (37:15): Bye, guys.

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:

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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 Epic build for Hot Dog Order.

Pryce Ancona (05:04): I am. I am thinking about this.

Brendan Keeler (05:12): Okay, we got some answers. Brad, Ryan, any hot dog guesses?

Brad Thorson (05:18): I’m actively Googling, which is exactly what you want to do here.

Brendan Keeler (05:22): That is cheating. You go last. I’m not letting you color the answers with Dr. Google over here.

Brad Thorson (05:38): Okay, so if I’m inpatient, how does the kitchen get my meal order? Is there a standard for this?

Brendan Keeler (05:45): You’re blowing it! You’re ruining it.

Brad Thorson (05:55): Listen, the answer is a custom FHIR extension. We gotta be able to put our ketchup and our relish on it if we need it. Or for you sickos out there, your mayo dogs.

Brendan Keeler (06:07): When you took tests in high school, Brad, were you the guy with the program on your TI-89 to cheat? Because that’s kind of what you just did.

Brad Thorson (06:13): Sure. I was just interested: do food orders go through the EHR? How does that happen?

Brendan Keeler (06:22): So the question I was going to ask is: is a hot dog a medication or a procedure? But diet orders do exist. There’s an HL7v2 interface for diet orders. The standard is ORM, but there’s an OMD message actually defined in the standard. And in FHIR, there’s a NutritionOrder resource, very specifically.

Brad Thorson (06:52): This is Education Corner.

Ryan Tucker (06:54): If we’re really going to educate, can I say how this actually happens? It’s not via an interface standard. The doctor gets the request from the patient. My wife’s a nurse. The doctor comes up to her and says, room three wants a hot dog, I don’t know what the hell to do with that, do you want to place an order for them? There’s a side web order panel where they can bring a menu into the room and let them order. It’s all outside those standards. That’s the reality of it.

Brendan Keeler (07:28): I am stretching. A diet order is more like, this person needs this many calories, and that flows over to certain systems. I’m the student who would stretch the truth in my essay to get an A. So we have the cheater in Brad and the guy who likes to change the definitions in me.

Ryan Tucker (07:34): Low sodium, things like that. Which a hot dog would not meet.

Brad Thorson (07:48): Hot dog is a medication. I can defend this stance. It’s clearly addressing a physical need, and we’re solving it through oral medication.

Brendan Keeler (08:02): Do you believe sandwiches, and is a hot dog a sandwich, are thus also medications?

Brad Thorson (08:06): Alright, this podcast is cancelled.

Pryce Ancona (08:09): I’m curious if some clinical data validation rule would fail if you made a FHIR query and saw that your patient had eaten 70.5 hot dogs. Because it’s very possible, if you were Joey Chestnut, that’s what you’d be doing in a few days. Make sure you get the units right. Maybe there are ancillary medications too, like a schnatton of water you drink as you shove hot dogs down your mouth.

Brad Thorson (08:32): Could be in your care plan.

Brendan Keeler (08:43): As part of the show notes, we’ll put together FHIR resources representing the Hot Dog Care Plan so viewers can import it into their CMS Health Tech Ecosystem app of choice. Have a great Fourth with your Hot Dog Care Plan. Last question: I’m going to name some ICD-10 codes and you tell me which Fourth of July activity they relate to. W39.XXXA, H91.9, and a couple others that relate to one particular activity.

Brad Thorson (09:27): Has Jason Pierre-Paul ever had these on his chart?

Brendan Keeler (09:31): You’re on the right track. These are all related to discharge of firework, initial encounter. I have one other fun Fourth of July ICD-10 for you, one I think we should pursue instead of those: Y93.G2. This is something outdoors you might do with friends and family, perhaps while instituting the care plan.

Brad Thorson (10:14): Lawn darts. Excessive alcohol consumption.

Pryce Ancona (10:14): Is it activity? I think it’s grilling and smoking food. Is that it?

Brendan Keeler (10:24): Grilling and smoking food. Wow. Pryce, how did you... my god.

Pryce Ancona (10:31): I got the old Struck by Orca on me right now.

Brendan Keeler (10:36): I was like, he’s just Googling on his phone. That’s awesome. So grilling and chilling is actually an ICD-10 code, and I think people should pursue that one this weekend, not the Jason Pierre-Paul one. That’s the Fourth of July segment. Now to our regularly scheduled agenda. TEFCA had a fun wrinkle this past week when we saw a contract awarded, out of the blue, to another non-RCE entity. Many people took this to mean the Recognized Coordinating Entity, the Sequoia Project, had been replaced. But no, this was a new contract focused on auditing new entries to the network. Thoughts on this move by the ONC and what it means for TEFCA?

Brad Thorson (11:30): I would say, fortunately, there have been no odd contracts awarded in the last couple of years.

Pryce Ancona (11:35): First, I’d say this is still very American: government contracts and capitalizing on government contracts. A nice five million dollar contract or something.

Brendan Keeler (11:51): It starts at 1.8 and then goes upwards, I think.

Pryce Ancona (11:53): I think it’s a little crazy that they need someone separate to police all of this. I understand they’re tied up in actually writing the policy, and it would be a lot of work to do all this auditing. But I wish there was strong enough conviction and trust in the RCE to just do this on their own, because I imagine they understand what abuse or fraud looks like in TEFCA a lot better than these external parties. We’ll see where it goes. I’m interested to learn what they’re actually doing, on what cadence, and whether they report out.

Brendan Keeler (12:42): One thing I’ll note: I think the RCE didn’t know about this. They may have been surprised. I think the ONC, Dr. Keane, Posnack, etc., said, okay, we need to do this, in response to January’s letter from all those hospitals. Something like 70 hospitals wrote in saying we need better auditing and security. And then Bob Watson, CEO of Health Gorilla, wrote in saying we need an independent body to do auditing. Combine those, and both sides of the Epic v. Health Gorilla case are asking for a similar thing: an independent body to resolve things. So they went outside the usual suspects, the health tech bubble, and chose someone from GovCon land who comes in with no assumptions and no biases. That’s the positive spin on it.

Brad Thorson (13:42): Part of the pitch Health Gorilla makes in the service they offer is verification: all their customers pay a fee to ensure none of the other customers erode their on-ramp. This is a failure of the networks to establish trust between parties. If your on-ramp isn’t doing anything to police its network, if they’re passing the cost back to the government, then why do we want on-ramps? Do we need thirteen QHINs if it just increases the complexity of auditing?

Brendan Keeler (14:23): Is your alternative a centralized service?

Brad Thorson (14:27): I’m not saying it’s the right decision. I’m just saying, if we’re creating an auditing function for independent services, isn’t that more efficiently solved, since we’re pivoting toward efficiency of government operations, with a centralized service provider?

Brendan Keeler (14:45): Logic doesn’t play here. You gotta go off vibes. Going back to the theme of America: we’re not built for big centralized services. That’s Europe. European countries say, alright, we got the big server, use this. We’ve gone in circles around that for two or three decades and said no, we can’t possibly build the big centralized database. But there’s validity to it, right? Maybe we’re contorting ourselves and all our problems are derivative of a decentralized architecture. I don’t know. Ryan, you have history here with Care Everywhere. Any thoughts?

Ryan Tucker (15:22): This harkens back to whether it should be a single payer system or universal healthcare. There are arguments either way. The US is the only team in the World Cup that doesn’t have that, right? In a perfect world it’s nice to have competition among on-ramp providers. It makes sense for Sequoia and the RCE to set the rules. They thought there’d be some policing on their end and some among the participants, and now there’s a greater need since an event came up. It’s nice to have an independent third-party auditor in some cases, but who’s chosen matters a lot. That’s where I have some skepticism. But it is very American, as we said, to have that government contract. Lockheed Martin and Palantir might have taken a look, although for 1.8 billion, probably not.

Brendan Keeler (16:23): 1.8 million. If it was a billion, different story. One thing I thought was funny: Bob Watson said we need an independent board like the SEC. Well, the SEC has four thousand people on a budget of over a billion dollars. So we got the budget of the SEC, perhaps. Pryce, thoughts?

Ryan Tucker (16:44): It’s quite low, I feel, for what’s being asked of them.

Pryce Ancona (16:50): Well, what was asked of them? Do we know exactly what tasks they’ll be executing?

Brendan Keeler (16:57): We have a hint. The hint’s gone now, unfortunately. The group that won is Alliance Global Tech, a DC contracting firm, prime contractors on a lot of these vehicles. They posted a site saying, here’s our TEFCA support and the auditing we’re doing, and then they pulled it as outlets started to report on it, because I think the ONC wasn’t ready for them to fully release that plan. But it alluded to using AI and other tools to efficiently monitor, audit, and detect people breaking TEFCA’s rules, either fraud, groups fraudulently using the networks and claiming treatment while selling patient data without consent, or information blocking. Which is interesting. I don’t think their focus could really be on information blocking, but the ONC announcement said both. I think it’s to signal, hey, we’re going after fraud, because everyone knows at this point the administration hates fraud. Of all kinds.

Pryce Ancona (18:07): Like all kinds.

Brendan Keeler (18:14): Well, maybe not grift. But fraud. Let’s take a look real quick, I’ll share Alliance Global Tech for the audience. Something that bummed me out: they had a website that was very patriotic, I would say, and they went to this AI-generated aesthetic. There are tells: the little sliver thing, the dashes in the writing. You can look at a website now and go, man, you slapped this together with Claude Code. But look at their old website. Fourth of July ready. Beautiful stock photos.

Pryce Ancona (18:57): That’s a great fighter jet. That would be really useful.

Ryan Tucker (19:03): There’s Lockheed Martin right there.

Brendan Keeler (19:05): I’m just extremely bummed they went away from that aesthetic on our 250th birthday. 2000s-era HTML, big flag, and then AI sloppiness. Aside from that: they’re a firm that’s been around, they claim to have worked with CMS, but their history of contracts as a prime is a little sparse. They’ve sold some hardware, they have a few things with the Navy. This is by far the largest contract we can see. So even though the role of an independent auditor sounds like it may be good, the question, as you said, Ryan, is whether this is the right group to do it.

Pryce Ancona (19:54): Maybe part of my frustration is that the Sequoia Project has had thousands of willing good Samaritans call in about how it feels like this doctor doesn’t exist, or this doctor’s credentials are being used to make these queries, and they’ve done nothing about a lot of that. And now, all of a sudden, this is what you slapped together? That’s my frustration. Hopefully I’m wrong, and a year from now we see really exciting drama about all the fraud this company found for the American people. But I’m not very excited for now.

Ryan Tucker (20:44): I feel the same way.

Brad Thorson (20:45): It feels like a market failure to me, and it could open a very large can of worms. The existence of a bunch of different on-ramps and the continued proliferation of fraud makes me feel like this space has an incredible amount they could be investing in. If they believe in competition, fine, taxpayers can pay 1.8 million dollars for an internal audit board, but police your own network and make that a differentiator.

Brendan Keeler (21:15): It’s tough insofar as so many people involved in Sequoia worked at EHRs before, worked at on-ramps before, and leave Sequoia to go to these companies. So there’s validity to impartiality. But that comes at the cost of expertise. There’s a tradeoff there. Time will tell. I take it positively, because I’m pretty optimistic in general: at least they’re doing something. They’re taking a shot on goal, and they may be wrong and have to revisit it.

Brad Thorson (21:55): When the OIG starts their information blocking work, when we learn what’s happening there, I think that’ll be encouraging, because right now the courts are handling the policing. Would this independent body have found instances of fraud earlier by throwing some AI at it? Maybe. And what’s the restitution? Action on the OIG side makes something like this look better. Inaction makes this look like somebody built a 1.8 million dollar swimming pool in their backyard.

Brendan Keeler (22:31): Good point. We’ve got court cases pending, and we’ve got the OIG and the government getting together on information blocking action. They alluded to that in September last year. You all went to that DC event, right?

Pryce Ancona (22:48): We all did. Everyone but you.

Ryan Tucker (22:50): That’s where we first met Pryce, actually.

Brendan Keeler (22:50): I was on paternity leave. So it’s coming up on a year. As we head into the second half: do we see information blocking enforcement by end of year? What does Polymarket say?

Brad Thorson (23:05): Well, let’s define enforcement. I would be floored if there’s any sort of resolution. But will we see action by the government? I’d also be floored if we don’t. The polymarket question is: what is the market cap of the first group of vendors that receive information blocking notices?

Brendan Keeler (23:37): I think it’s end of summer. By end of summer we see something. I don’t know if it’s an investigation, enforcement, DOJ or FTC action, but something’s coming, and I think it’s Epic. Who else are they going to wield it against? eClinicalWorks?

Brad Thorson (23:58): They could go down market. I don’t want to start naming companies and pretending we know they’re information blocking, but if they start going after companies with hundred million dollar market caps because it’s easier to take action, I won’t be as excited.

Brendan Keeler (24:18): That’s part of it. I think there are more egregious information blocking behaviors from some rando long-tail EHRs whose FHIR servers don’t even work than at Epic, where the problem is more like: you’re trying to push a condition into Epic or do HCC coding, there are seventeen options, and you’re overwhelmed about which to use. Down market it’s more like, no, we have a scribe, you can’t connect. But if the goal is to please a certain constituency, going after those won’t please them. Going after Epic will. So I cynically think that’s where we’d see action first.

Pryce Ancona (24:56): Another thing to note: the concept of information blocking was written to empower patients, but I see it as a market equalizer. A prevention tool for vendor lock-in, software lock-in, being stuck because certain companies know the data they manage is important. The idea that information blocking as a law is so unique to electronic health records, and, as Brendan always points out, car sales tools in Arizona, says to me: if we’re going to balance the market, we should apply more scrutiny toward market participants who saturate and overwhelm competition in a way that prevents new entrants. So I agree with everyone on this call. Epic might be the most common accused committer of info blocking, because people ask to connect with them a thousand times a day and one person asks to connect with eMDs every year. But they’re the furthest from actually breaking the law, in my opinion, as it’s written. It’s just more useful for balancing the market when you use it on a company as big as Epic or Oracle.

Brendan Keeler (26:40): I’ll push back on that. I agree in one sense, but in the other: get it done. Get one enforcement done and it’s suddenly real. With that as the driver, you might choose a target where the behavior is egregious and truly provable. Then you can say, this is what we’ll do and what we’ve done. It took a while to get HIPAA enforcement in place and prove it, and then it became real. I hear you on the blast radius of doing it to Epic and positively influencing the market. But if it takes five years because of their legal muscle and because they’re not the most egregious, you lose the point. The enforcement isn’t the thing that needs to happen for all one thousand eight hundred cases. You need proof points to use as leverage, as a patient, as a third-party application, as someone whose information is being blocked. If I were the OIG or ONC, I’d chase down one clean example.

Pryce Ancona (27:45): Couldn’t they just say, there’s our first one, PointClickCare, because it’s already been proven in court? Or is that double jeopardy, since it’s already been settled in a state tort case?

Brendan Keeler (28:17): How I imagine it playing out: as they work through these, it could lead to legal action and go to court, and if it’s already been in court, there’s going to be consolidation and precedent. But to be clear, the PointClickCare preliminary injunction gives a lot of confidence in the pathway, but a preliminary injunction is granted when there’s acute harm that needs rectifying while the trial progresses. RTMS is going toward trial, and probably settlement, it looks like. We saw updates this week pointing strongly toward settlement. The preliminary injunction found it highly likely RTMS succeeds on the merits, and on appeal the court agreed with that logic, which solidified use of the pathway. But you still have to fight the merits. The trial has to run its course before someone’s guilty. And because that one is so far along, I think they’d choose something new. And people might sue the government in response to this. If you’re an EHR vendor and decertification is on the table, you’re going to fight it, because you’ll go out of business if you’re decertified. People imagine the ONC and OIG just saying, you’re off the list. No. People will fight it, because certification is a survival mechanism for many EHRs.

Ryan Tucker (30:15): I love working with y’all, because my thoughts on this have changed as we’ve gone person to person. Will we see enforcement in general by end of year? I think we might see investigation. I don’t think penalty notices will have gone out, but maybe more detail on action being taken. I was first thinking Epic, as Pryce said. Even though we all agree they’re not the most egregious actor, they have a lot of openness, they participate a lot in exchange, the impact would be highest with Epic in both volume and news cycle. But Brendan, I think you make a good point: that will get the most stuck, be hardest to prove, take the longest, and they have a huge legal team to throw at it. It would be great to just get one out there that shows enforcement. Because the biggest question right now, despite notices going out, despite there being a boot camp we attended, is: will enforcement actually be real? Until we get that first case, it’s wait and see. Even if it’s a small actor, the impact will be felt, because then maybe Epic starts moving and says, okay, it’s real, we should protect ourselves.

Brendan Keeler (31:52): Good point. And I want to make sure we’re not seen as a bunch of homers because we used to work at Epic. We keep saying, as a matter of fact, something people will have an emotional response to: that Epic’s not the most egregious information blocker. For many people that’s an emotional, anecdotal reaction. Our perspective is aggregate, across our clients, watching how they connect to Epic through the developed pathways, HL7 and APIs. If you follow the process, joining Vendor Services, submitting a tech guidance form, pushing Epic, they’re pretty responsive to the Manner Exception in the way we see major EHRs be responsive. They engage in good-faith negotiation to identify technologies to connect, even permitting RPA where they don’t have a pathway. Many people just don’t engage in that process, assume they’re being blocked, or can’t sell and assume they’re being blocked. Go down market and you see EHRs with no APIs, APIs that don’t work, or vendors who won’t let you connect because they want to sell their own product. That’s far more common: outright blocked down market, up s**t’s creek, because they don’t have a legal team that understands information blocking and the Manner Exception. That’s what we’ve seen helping apps connect. Do you agree?

Pryce Ancona (33:34): Yeah. Even if down market you can attribute it to Hanlon’s Razor: don’t attribute to malice that which is adequately explained by ignorance. It’s hard to compete against Epic, and a lot of people imagine Epic is info blocking when they go sell their product to a CIO at Johns Hopkins and he or she says, no, we don’t want your product. That’s not info blocking. That’s not winning business at a massive enterprise. Or maybe you get there and the CIO asks, how are you going to integrate with us safely and securely without taking all my resources for two months? If you don’t have an answer, tough s**t, they’re not going to integrate with you. That’s not info blocking either. That’s not winning a contract. On the other hand, we’ve paid much more to join the vendor partner network for a non-Epic EHR that is much worse on documentation, feature availability, and support. Obviously the four of us have biases, and everyone probably thinks we’re all getting paid by Epic under the table. I wish I was, but I’m not.

Brendan Keeler (34:50): I have a few Epic people who subscribe to Health API Guy, so I guess I’m taking a few dollars, but far more from the rest of private industry. Brad, you have a thought.

Brad Thorson (35:03): I have an orthogonal prediction for the summer that will be directly impacted by information blocking. If I’m sitting in a corp dev office, I’m thinking it is not going to get easier to buy companies next year. So there’s likely a consolidation push coming. And the problem is, I don’t think I’d go out and buy certified health IT right now, because there’s huge risk associated with it. I don’t know what it’s going to look like, but I would not be surprised if a number of relatively long-known names come off the table pretty quickly, before September, October conference season.

Brendan Keeler (35:48): Because of midterms?

Brad Thorson (35:51): Yeah. I assume the government’s posture toward consolidation changes with a shifting congressional balance. If you’re making the choice and it’s more than a coin flip, or even if it’s a coin flip, do it now, don’t wait. Which will be odd given the general economic uncertainty, but find me a polymarket around consolidation of on-ramps and other non-certified technologies.

Brendan Keeler (36:26): Ambient scribes?

Brad Thorson (36:28): That would not be surprising, although I’d be surprised if it was ambient scribe to ambient scribe. Brendan, you’ve written about this: we’re seeing jobs-to-be-done compress into each other. If you can pick up an E&M coding startup for really cheap, not have to build it yourself, and potentially inherit a pathway in for integration, hell yeah, go spend a couple million dollars.

Brendan Keeler (36:52): A really good prediction, and true. What about year two of the CMS Health Tech Ecosystem? We’re coming up on the big launch. New round of stuff? Predictions?

Pryce Ancona (37:07): As a friend of the ecosystem, I’m predicting a lot of friendship over the next year. I can see myself becoming friends with everybody in the ecosystem. No, I don’t have more serious thoughts than that. I’m excited to see the rubber meet the road: CMS finally has to say these pledgees are now participants, they have pledged and they have fulfilled. And then I wonder if we see a ton of names just drop off the list, all these PR departments deciding this has fallen out of the news cycle and compliance isn’t as important to maintain. But as Brendan has said before, maybe that doesn’t matter. Maybe what matters is that the Cleveland Clinic and Epic and eCW and Flexpa and Fasten show the rest of private industry that patients can download their information from nationwide networks, take it to the doctor’s office, and give the front desk a FHIR or CDA payload to load straight into the EHR. And then what does any of this matter if it’s written into HTI-9 or something a year or two from now? One more thought: the e-prior auth group that just started up has been exciting, a lot of movement. Part of that is everyone tracking toward 0057 compliance, so there was a head start on that work. But it’s fun to see CMS rally the troops without a carrot or a stick, in some sense.

Brendan Keeler (38:47): To your point, you said HTI-9; I think it’s HTI-6. We’ll see HTI-5 finalized in the second half, and HTI-6 could wrap in the market-adopted, piloted features. Half the value of the CMS Health Tech Ecosystem is to get market adoption and proof points for standards and data flows. That’s a prerequisite to inclusion in SVAP and the certification program, all these processes we built up. Well, they just speedran it. And as a result, hypothetically, anything in there that’s market adopted and proven could be required by the ONC. I imagine CMS may lean on them to do so. But maybe that’s where you were going, Brad, and I stole your thunder.

Brad Thorson (39:46): No. I don’t know if this will be mandated, but: Medicare Advantage plans will institute IAS and pass their gaps-closure problems off to, harkening back to a previous podcast, payvider organizations, cutting out major regional partners. We’re gonna see drama.

Brendan Keeler (40:06): That’s a spicy one. We’re coming up on time. Ryan, any last parting prediction? We didn’t get any Ryan predictions.

Ryan Tucker (40:16): I think it’s going to be more depth within the segments already at play rather than breadth of new segments. Prior auth is kind of an exception, but greater payer involvement, ACO involvement, things a lot of folks would love to see... as we’ve seen with TPO, as soon as you go past patient-focused treatment into operations or payment, things get infinitely more complicated. There are many different motivators, and you don’t necessarily know what’s right. So I think they stick with the main segments they have but go deeper. I still use a clipboard when I go to my doctor’s office. More things for patient management and communication within the same segments, rather than going past them.

Brendan Keeler (41:10): Solid line drive down the fairway. That’s got a high percentage on Polymarket. Well, happy Fourth of July. Go get that hot dog, stay away from the fireworks, and we’ll see you soon.

Ryan Tucker (41:23): Stay safe.

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 through it. The first question is “What is Particle’s definition of the relevant product market?” I don’t know if anyone has thoughts there.

Pryce (05:03): Interesting too, the wording there is what is Particle’s definition? But then both Epic and Particle have to answer that.

Brendan Keeler (05:09): They’ve kind of skated all over the rink with this one. The judge is like, all right, we’ve already been going for a long time. Let’s agree about what the original assertion was, which is wild to your point.

Brad Thorson (05:22): I mean, are we getting into the definition of a payvider? ‘Cause that’s where this all comes down to.

Brendan Keeler (05:27): Well, that’s exactly question two. How do the parties define payer, payvider, and provider?

Brad Thorson (05:33): Okay, so going back to question one in defining what the market is, maybe a question for Brendan, ‘cause I don’t know how closely I read this. When they list the number of customers that they have, was that at the point of the lawsuit or is that today?

Brendan Keeler (05:48): Yeah, Epic backdated their customers. But it was also said that they’ve progressed in selling their payer platform.

Brad Thorson (05:55): One takeaway from this is EPP is bigger than I thought it was, if that’s backdated. What Particle’s definition of the market is doesn’t really matter outside of what a payvider is, because that’s where this all to me kind of fell apart. And I don’t know if that’s a law firm thing because they were forced to speak in plain English, or if we really just want to have this aggressively broad definition of payvider. But Epic’s lawyers came in strong, expecting what Particle was gonna say and just saying like, everybody cannot be a payvider.

Brendan Keeler (06:32): Is a payer platform a thing in your guys’ mind?

Brad Thorson (06:37): I mean, if we’re talking that payments and operations are a separate rail of requests, then yes.

Brendan Keeler (06:42): Pryce, you’re shaking your head.

Brad Thorson (06:45): You can do the queries over the same rails, but it’s outside of the spirit of, well, we’re gonna get into Carequality in a second.

Pryce (06:52): The payer platform as defined, like Epic’s answer to number one, is that it facilitates record retrieval at scale. And what this really means is, we can help collect CDA documents, which is the clinical document architecture standard. All of the electronic health records should be able to grab the problems list, the allergies, the medications, the immunizations, some encounter details, hopefully some labs, jam them into a chart summary, and exchange these on nationwide networks, right? And that happens in the billions today for the purpose of treating providers seeing these documents to treat patients. And of course, or maybe not of course if you didn’t know, payers will pay out the wazoo for this type of data. They want to know: of my 100,000 sickest patients, if I could get all of those chart summaries, I’m willing to pay Athena. I’m willing to pay Datavant to go fetch them. And I’m a covered entity, I’m allowed to access these things. They’re just not supposed to be doing it over the rails of some of these nationwide networks that say “we only exchange for treatment purposes right now.” But that’s what they’re aggregating, so that they can do analytics and say, of my sick patients, how do I make them healthier? How do I spend less money and make them happier? Hopefully retain their business or their employer’s business.

That’s too amorphous of a job to me. It sounds like I just described it simply, but there’s a hundred different protocols that you could use to communicate those documents. There’s a hundred different standards that you could use to communicate the same type of data in those documents, even though I was calling out one standard. There’s a hundred different entities and rails. So to me, this is like, is there a product market? Well, I don’t know. Would you say there’s a hammer product market? Or is there like a heavy metal thing that you whack nails with? Sometimes it’s like a hammer, sometimes it’s like more of a mallet, sometimes you use the butt of your drill if you’re in a pinch, or you’ve got an impact drill on your belt. That’s what’s happening.

Brendan Keeler (09:00): That’s right. Are they substitutes? And that, for question one, is the tough part for Particle. They need to say, okay, these are substitutes, right? There’s Epic Payer Platform and the way we’re doing it, even though they do it different hows, one’s the butt of the drill and one’s a more fit-for-purpose tool potentially, but they’re the same. But at the same time they need to say it’s only the two of us. There’s not these other things.

Pryce (09:26): That’s the hard part to me.

Brendan Keeler (09:29): But they’re trying. So their answer for question one, let’s go through it. Particle said payer platforms are software enabling healthcare payers to collaborate with providers in value-based care models, defining features of real-time, bidirectional, at scale, clinical data plus alerting, analytics, and longitudinal storage. Well, why, if you squint at it, is that a clearinghouse? Is that a population health tool? Innovaccer is named in the case.

Pryce (09:48): That’s a clearinghouse.

Brendan Keeler (09:56): There’s a tough look there. It’s also interesting that they’re saying VBC so prominently, right? That VBC is one of the defining characteristics for these payer platforms.

Pryce (09:57): That there’s some aspect of risk bearing and the potential to capitalize by avoiding that risk. That’s what they’re saying there. It’s not just for the purposes of processing claims, it’s also for the purposes of avoiding future claims.

Brendan Keeler (10:25): They say if a payer takes an active role in improving the health quality of its members, that is their primary angle of attack.

Pryce (10:34): Which, again, I don’t disagree with what they said about a payer platform. I’m just gonna come out and say the same thing is true of a delegated authority who only manages your patients’ or members’ medication adherence. And it’s a completely different type of company. And the same thing is true of an entity who uses telehealth to manage all of your musculoskeletal members’ needs. It’s just way too broad in my opinion.

Brad Thorson (11:08): It’s also a bold set of letters to lean on when I don’t think that we could get the three of us to agree on what the clear definition of value-based care is. This to me felt like, we’re just opening up a different drain for Dino to swirl around for a while, because the three of us will have different definitions, and when we go ask three hundred strangers on the street, they’re not gonna know what it means. But we’ll also probably describe it differently as well. Reading VBC in this definition, I was like, no.

Brendan Keeler (11:39): So question two: payer, payvider, and provider. What do those mean to you guys?

Brad Thorson (11:45): Okay, so provider’s straightforward, right? We can all get to the same definition of provider. The delivery of care. And where we’re gonna end up having to argue is what happens when United owns Optum, or any of these other payers have a care delivery arm. But to me, not a lawyer. Somebody put a really big warning on this podcast that none of us are lawyers.

Brendan Keeler (12:11): IANAL.

Brad Thorson (12:13): I really struggle with the idea that providers in value-based care arrangements are not typically looking at the long-term risk of that population. They’re looking at like a defined period, 90 days after surgery, a year of enrollment or whatever. And for many payers, one of the major things that they’re doing is risk pooling across an enormous population. That is, if they have any function at all, it is that. And so that to me is where I feel pretty confident drawing the line on what’s a payer.

Pryce (12:47): Particle says a payer is an organization that assumes the financial risk of paying for a patient’s health care. And to your point, the reason you can do that is through actuarial sciences and grouping a bunch of people together and saying, on average, they’ll be this sick and we’re gonna have more money than that to care for them.

Brad Thorson (13:01): Yeah, but my problem is that feeds into their use of VBC, of like somebody who has an ACO and is accepting a fixed fee for their patients for the year. Yes, they are doing some sort of risk analysis of whether or not they think they’re gonna be able to deliver care at a lower cost than that. But it’s not at the level of, what do I think my oncology risk is across 30 million patients. They’re not doing the level of modeling to offer an insurance product. That’s my assumption: there is an order of magnitude difference in what those types of risk-calculating orgs are doing.

Brendan Keeler (13:39): In the interest of time, I’ll say the responses from Epic and Particle agree with you. They kind of land in the same spot where payer is a financial risk bearer, provider delivers care, and both of them say, well, payvider, in Particle’s terms, is just semantics. Like, what if instead of payvider we said payers engaged in value-based care as the group we’re talking about? Which is funny, because then you probably should start by saying that in your opening brief. Typically it’s not great to throw twists into these nuanced five-pager briefs as like, we’ve been talking about this the whole time. And then Epic is like, we disagree with the use of payvider as industry jargon. Which is interesting, because I remember that being a term when I was at Epic. Or maybe I’m hallucinating and it’s come into vogue since then. To me it always has described like Providence before they got rid of their operated plan. That was a payvider.

Pryce (14:39): I like Epic’s take. They say Epic did not endorse the term payvider. Which I kind of agree with. I would use the term payvider with you two. If I was giving a presentation, or if I was, I don’t know, maybe submitting documents to a judge, I don’t think I would say payvider. Is Apple a hardware or software company? Well, it’s both. And there are times that they’re completely separate and there are times that they’re inextricably intertwined.

Brad Thorson (15:08): A services company. That’s the answer. Pardon the divergence.

Pryce (15:11): Yeah. So it’s tricky though.

Brendan Keeler (15:13): Thank you, Tim Cook. What’s interesting is there’s some interesting stuff in the Epic letter that we haven’t really seen before. They say, well, when we have a payvider customer, they may have two instances of Epic, basically. They’re gonna have the provider group Optum and the payer group United on separate instances of Epic. And I wonder if that’s true for all payviders. I thought I remember there being one where it’s a merged instance and just, you know, UPMC is on one big old both-insurance-and-healthcare side. But maybe not. Maybe Epic does segment them in that way and thus keeps a clean boundary when allowing for certain functions.

Pryce (15:57): That’s not a function of technology. It’s a function of compliance. These people are not supposed to be allowed to see this data. And that’s normal. It’s probably smart of them, very calculated. But the whole point is, being a payer shouldn’t allow you access to crisis behavioral health notes, right? Just because. That’s gonna be in the weeds of state privacy laws and federal privacy laws and HIPAA and blah blah blah. We don’t know enough about that, but very interesting that they create that dichotomy.

Brendan Keeler (16:31): Question three. What percentage of EPP and Signal’s customer bases are payers, payviders, and/or providers? So what do we think? Are they selling to payers? Are they selling to providers? Are they selling to payviders? Any guesses on what shook out in these responses?

Brad Thorson (16:51): I mean, Particle said all of their customers at time of suit were payviders of the Signal product, which is also a can of worms I don’t want to open with you guys, but on-ramp product names are not something I’m fluent in the way that I know Spanish when I’m drinking.

Brendan Keeler (17:08): Signal is new. They added Signal to the mix after they filed the case. Once they filed the case, they were kind of like, okay, we’re selling Signal to payers. Prior to then, a little bit more behind the scenes. Pryce, any guesses?

Brad Thorson (17:19): And their delegated authorities. Sorry, go ahead.

Pryce (17:27): I guess out of the gate, none of these are providers. They have to be either payers or payviders, and there’s a mix. There’s gotta be a mix. You can’t have even up to three different customers and be like, they’re all payviders. I would be like, well, Aetna is a payer. I understand it’s owned by CVS Health, but let’s just, I think that goes back to Epic’s assertion that payvider is a nice term to use on the fly when you’re talking to someone. If we’re gonna define things, let’s define them black and white. So to me, yeah, you could call them payviders, you could call them payers, but there’s no way that you can call them exclusively payviders, in my opinion.

Brendan Keeler (18:11): So as you guys predicted, Particle says a hundred percent of payers for Epic Payer Platform are engaged in VBC. Signal, hundred percent payviders, same market, selling to the same people. That’s Particle’s take. Epic said we got twenty-three payer customers as of the time of the complaint. We have more now, but we’re backdating this thing. And then we also have provider customers. This was the twist. Because Epic Payer Platform is on both sides, right? You’re connecting over Epic Payer Platform to provider customers who must have it installed and set up to participate. They haven’t really talked about it from that angle, and it might give Judge Buchwald some reason to pause and be like, are these the same product? Are they the same users? Is the alleged market correct?

Brad Thorson (18:40): Three hundred plus?

Brendan Keeler (19:01): It’s kind of a smokescreen, I think, from Epic, but it was interesting to see them mention provider users as a wrinkle in this take-home exam. Question four we can kinda skip over. What further discovery does Particle need? Full merits. Let us get in there and see what we can dig up. ‘Cause that’s the whole point.

Brad Thorson (19:17): All of it. Yeah. And Epic, obviously they’re totally aligned with Particle on that one.

Brendan Keeler (19:29): Particle is super jealous of CureIS, because CureIS got moved to Madison in Wisconsin court by Epic’s push. And then because it did, that’s a rocket docket. They move very quick. And so they’re already doing discovery there, even though they’re still ruling on motion to dismiss and stuff. So I bet you they’re squinting like, man, the jurisdiction here, the venue here kind of handicapped them in their case.

Brad Thorson (19:56): To your point, question four, probably not a whole lot for us to discuss.

Brendan Keeler (20:01): Well, the last thing is Epic had like one sentence. No further discovery is necessary. What did you think they were gonna say? Question five: does a pure payer take an active role in member health through value-based care?

Brad Thorson (20:15): It’s a bad question. It’s a question that should have been asked as an addendum. Once we’ve graded the exams and we have to decide which one of you, if you’re both equal, then we’ll ask you this question. This is just a derivation of the answer to question two. I didn’t get much from it.

Brendan Keeler (20:31): Should a payer be trying to push a provider to do the right thing, push patients to do the right thing? Yes, that’s distinct in some ways from treatment. That’s the crux of the issue. Is oversight over care towards the right alternatives, the right care pathways, ownership of financial risk, does that equate to treatment based on the activities? That’s behind this question. And Particle says yes, payers bear the financial cost, so they’re self-interested to improve health, and that care coordination is treatment enough. And Epic says no, only providers can conduct treatment. They quote HIPAA very directly, the 2000 privacy rule, and payers can help improve care, but only a provider can provide care. That’s their angle, and they try and make the question irrelevant by virtue of that.

Brad Thorson (21:24): And I think that’s what you’re saying, Pryce. The use of payvider for people like us puts multiple people in a trench coat, but really there are multiple people under there. There’s also the definition of payer. There’s just too many strings to pull here. Why do employers have EAP programs? Sometimes it’s that they don’t think their TPAs are providing the right types of services. Sometimes it’s for retention. There’s all sorts of reasons that an employer, when they’re self-insured, may decide to introduce a bunch of services. I don’t think that we would consider Google to be a provider because they give their employees free therapy sessions through a third party.

Brad Thorson (22:10): Payvider is a bunch of things in a trench coat is the way that I’m gonna stick the landing here.

Brendan Keeler (22:16): That’s what Epic does say, right? They’re like, Particle’s definition is so broad it could be anybody. It could be you and me. Is that right or wrong? It’s a compelling argument.

Pryce (22:25): We said improving health, absolutely, payers can improve the health of their members. Treat? That’s a little bit more like, you should have an NPI in my opinion. There should be an encounter documented. And then don’t you have to bill yourself for that or something? There’s all sorts of laws that would have to do with treating. But now I’m even thinking, imagine one of the strongest payviders in the world.

Brendan Keeler (22:44): Money here goes to money there.

Pryce (22:53): Who does a great job of knowing their members and does a great job of primary care and preventative care and benefits. Even still, when and if I develop congestive heart failure, I’m gonna go see a cardiologist. And it might be at like a UCSF. And guess who’s gonna pay for it? My payer, who has been treating me well. I’ve had a longstanding treatment relationship with them, but at some point they’re just gonna be my risk-bearing entity. They can’t do it all. So I think there needs to be, okay, we understand that there’s a Venn diagram, but that doesn’t mean payers and providers can become the same thing without any sort of barrier between what they’re doing.

Brendan Keeler (23:38): So that linkage leads to question six, right? Which is, what is Epic’s definition of healthcare operations? We talked about what treatment is, what’s operations? I’m just gonna say what they said and you guys can muse on it. They both pointed to the HIPAA operations definition, unsurprisingly. And Particle’s just like, this is what operations is, next question. Epic said this is what operations is, which is inclusive of things like quality reviews for HEDIS, clinical guidelines for conditions like diabetes, patient safety activities, fraud detection. They went a little further to talk about what goes into operations, to sort of say these are administrative, these are not direct patient care, and Epic Payer Platform is built for those administrative and quality functions, not for treatment. So they used it as a launchpad to differentiate. Are you guys convinced by Epic?

Brad Thorson (24:40): What’s funny about this case is, the time that I’ve dedicated to being in interoperability kind of started around when this case originated. It basically describes what I always assumed payment and operations was, which was very validating to my own feelings. So I felt myself very aligned with Epic’s definition. That said, I’m the youngest one on this call, interoperability-experience-wise.

Pryce (25:06): This is all a spectrum, life is complex. At the end, all things come to a confluence and a river runs through it, right? And that river is what separates operations and treatment. I think a patient has to be involved in treatment. They gotta be there, or they gotta go pick up a med, or they gotta start taking the med, or they gotta hear their provider tell them something. Calculating my HEDIS metrics to decide if I can be more compliant next year is operations. It’s not treatment. I don’t care if it’s going to lead to treatment, but I do see a fine thread somewhere through the spectrum separating treatment and operations. And I think that’s necessary if we’re going to continue to lean on HIPAA indefinitely as the law of the land with regards to these different types of activities.

Brendan Keeler (25:57): Putting the case aside for a second and going back to the first article I wrote about this arena: it’s just b******t that we’ve set the price to zero and the cost of exchange to zero for one, but market rate for another that is a hundred X more expensive via more manual, less ubiquitous methods. That becomes problematic because people go, well, treatment is per patient in front of me, but what about if a provider is pulling data to review meds and think about things without a patient being in front of me? What if a patient’s been over the video call with me with telehealth? They’re not in front of me. What if it’s an async review? So we eroded away from your point, Pryce, what you posited, which is, well, if a provider’s involved and they’re doing some sort of treatment activity, it’s treatment. And then people look and they go, well, if Dr. Smith’s doing it for UCSF, and then Dr. Smith goes to work for Cigna and does the exact same activities, pursuing the same outcome, then why should he or she not have the same capabilities and rights? Why do they have to pay a much more expensive experience to go and push towards the same outcome of improving a patient’s health? So population health, in addition to telehealth and asynchronous care, eroded away some of the cleanliness of all these definitions. And now you throw AI bots and s**t in the mix and, good luck. Good luck trying to keep the two definitions separate. So what’s it mean? I think it means that the reality of where we need to go as an industry is finding a way to bring parity and allow operations to be functional and cheap so that we don’t have to have this weird arbitrage. The arbitrage ability of artificially setting the price to zero and allowing market rates and a shittier experience to be prevalent for the other side of the coin is the problem.

Pryce (27:50): We all might agree that the definition doesn’t really matter, except that right now the goods are priced at extraordinarily different rates. But if it was all just data, we would be like, yeah, as long as they’ve got an NPI or they’re a covered entity, who cares? Is that your assertion there, Brendan?

Brendan Keeler (28:09): That’s why it’s so important for us to find a way to ubiquity and similar price points, or there will always be an arbitrage opportunity and people will abuse the networks. Period. That’s incentives, people will follow them.

Brad Thorson (28:19): “Do incentives lead to fraud and abuse?” Sure, we don’t need to argue that here. I think we’re in agreement. I’m just imagining an HOV lane versus a regular lane. If we’ve all decided that an HOV lane must meet X requirements and there’s a single person driving in it, they get a ticket. There is not a world in which we suddenly just make payment and operations free or start charging for treatment. I feel like the definitions that came out of this exercise were very clear to me in a way that’s the spirit of the law as I’ve always understood it. And yeah, it would be great if we had the ability to say this is operations and I’ll pay into a Stripe account or something.

Brendan Keeler (29:01): I took us down a rabbit hole that is distinct from the case, and you’re right, this is such a clean case, clean brief, and I’m like, well, this is the way things should be. My end of the side quest here is, the rules can change. We can make up whatever freaking rules we want in this life, in this world, and we just have to go and see it through. And to me, we’re gonna have a million of these cases, because we already do. Since this case started, there’s been this—

Brad Thorson (29:26): The new rule is that your insurance plan is going to incentivize you to connect to an IAS network and upload your information to them and just call it a day.

Brendan Keeler (29:38): Is this sponsored by B.well? What are we doing? Anyway, moving on to question seven. Can Epic Payer Platform and Signal be used by different types of customers in different ways?

Brad Thorson (29:52): I think they have different types of customers, so yes.

Pryce (29:55): I’m far from a lawyer, so if anyone who really understands this case is listening, they’d probably think I’m an idiot. But a question like this to me is just, what is Particle gonna say to that? Of course they’re different. Of course they serve different things. What is it, a Family Guy meme or something, where all of the animals on the ark make a new animal that’s got the trunk of an elephant and the body of a giraffe? That’s what these tools are. They’re just functions patched together. Somebody decided to write a line of code and then it could be combined with a million different permutations. There’s no way that Particle can say these are the same products serving the same types of clients. But what did they say?

Brendan Keeler (30:39): Maybe this is the crux of it, circling back to the beginning where I’m like, the whole point is there’s gonna be disagreement, they’re not gonna agree about things, and this makes or breaks the case for them, right? Particle says yes, we both offer similar retrieval and storage and analytics functions. Any differences are just implementation differences, HIPAA purpose abuse doesn’t matter for the antitrust market. Epic, as you may expect, says, we have payer customers, we have provider users that Epic Payer Platform is segmented out to each of those. Signal is only used by payers querying one way over Carequality for treatment purpose of use, whereas Epic Payer Platform doesn’t run over those rails. It doesn’t use Carequality or other network exchanges. It can’t even retrieve from Oracle and Athena, which Signal can, right? All that to say, Epic says they’re different.

Pryce (31:34): I think there’s some merit in Particle’s response here, which, like you said, was both products provide a range of similar functionality for entities engaged in value-based care. There are differences at the margin, but they serve core retrieval, storage, and analytics functions that support VBC. I’m like, that’s a great answer. It also suggests that maybe you two aren’t the only ones doing this. It’s not a high bar. There’s not a difficult, what is it called when you enter a market or whatever?

Brendan Keeler (32:02): Barrier to entry.

Pryce (32:03): Yeah, if you’re explaining it this simply, how could you possibly assert that you were the only two doing this? So that’s my take.

Brendan Keeler (32:12): That’s the problem. Going back to earlier, they’re stuck between being like, no no no, these are the same market, we’re serving the same types of customers, and then also being like, no no no, but the Innovaccers of the world, the Arcadias of the world, anyone else that’s doing HCC coding, providing data, those are different. That’s tough. It’s just a tough look that is the reason we had this wonky phase one and this weird take-home test. They’re trying to thread the needle here. Okay, we’ve got a few minutes left, so let’s try and get through the remaining questions. Can a payer or payvider request records for treatment purposes through Epic Payer Platform or Signal?

Pryce (32:53): I don’t know the answer to this. This depends on their software.

Brad Thorson (32:58): Didn’t they both say yes?

Brendan Keeler (33:00): Particle says yes to both, right? Signal is for treatment. “Carequality says it’s permissible” is what they put into their response. “Epic might say that they’re only payment operations, but we have proof via discovery and their litigation position that they’re doing treatment as well” is what Particle says. A lot of this is redacted, so I don’t think that we actually see the proof. All the spicy stuff unfortunately is blocked. But Epic says no for Epic Payer Platform. They say you gotta be a payer, you gotta be doing it for operations and payment, it’s gonna be minimum necessary, whereas Signal is treatment. This and question seven are the critical ones, or could be the critical ones, for market definition.

Okay. Is HIPAA purpose of use a defining characteristic of a product market? If we’re saying whether they’re serving the same market, if we take Epic’s answer as correct, that Epic only pulls for operations or payment, Particle only pulls for treatment, does that mean by default they’re separate markets?

Pryce (33:44): No. Jackhammer, break things. Hammer, break things. Backhoe, break things.

Brad Thorson (34:14): This is the market distortion based on fees. This is Brendan’s can of worms, and I think we should just call it Brendan’s can of worms as the going-forward industry definition.

Brendan Keeler (34:26): Correct. It’s not, both of them say no. Particle says very clearly, nope, interchangeability. Jackhammer, the break-things test. I hope this got referenced in cases. The Pryce Ancona break-things test is a true antitrust test. It’s interchangeability, reasonable interchangeability of tools and of products. And they don’t care how they get data and what they can do with it. They hand-wave at secondary use and all that stuff that I don’t think we really need to get into. Epic says no, but if you actually look at the purposes of use, the distinctions, you can understand that they’re not reasonably interchangeable, because you’re getting records from just Epic providers, because you’re serving different client bases. So if a payer using Epic can’t switch, or vice versa, a treating provider can’t switch and use Epic Payer Platform, then they’re not substitutes.

And this actually gets to where they denied Innovaccer, right? Particle says Innovaccer is not a relevant competitor because it doesn’t query national interoperability networks to retrieve new clinical records across unaffiliated providers. Well, if that’s true, Epic says, neither does EPP. And that’s a really compelling argument.

Brad Thorson (35:43): Neither does EPP.

Brendan Keeler (35:50): Right, to utilize Particle’s own words against them.

Brad Thorson (35:53): Or, as the redacted content may say, Particle knows that that’s not a true assertion.

Brendan Keeler (35:59): Yeah, suffice to say, I think Particle has killer lines in theirs similarly, using Epic’s words against them. It’s just unfortunately redacted, whereas this part is not. Question ten, to close it out. Extra credit. Under what circumstances can Epic Payer Platform be used for treatment-related purposes?

Pryce (36:09): Extra credit. Brendan, you sort of disagreed with this earlier, but I don’t think it can.

Brad Thorson (36:24): The fact that they highlight Carequality rulings in their response here, that business associates can make that request. Isn’t that similar to what Particle was saying above as to why they think these are similar offerings?

Brendan Keeler (36:40): Yeah, I think you’re right to call that out, that Particle multiple times references the decision-making of Carequality. That being said, this is the same question as the one above it. Epic says we don’t do treatment requests, it can’t be used for treatment. So I think Particle uses this as a method to talk about the way that they legally pull data and the proof that they’re doing so prior. Epic just answers it point blank and says “we’re not.”

All right, well, that’s all ten. Do we want to grade the test? How do we think each party did?

Pryce (37:18): I couldn’t even keep track. This feels more like the honorable Naomi Buchwald has become the first ever philosopher of treatment and operations than some sort of mathematically true-or-false test to be graded. But I would say maybe my take would just be this. These are really, really interesting questions. And I like the way they were phrased, sort of to peel away what is a very fine film here that connects these use cases and products. But I think the answers on both sides, in my opinion, sort of scream like it’s not a small market. It’s not a single thing, a single job to be done. It’s not based on how you do things. It’s very much like what you’re doing and when you’re doing it. Epic, I think, has receipts to show, we’ve been down the straight and narrow path with regards to not using this network for this purpose, and we serve payers and providers very distinctly. I think it gives Epic the upper hand. But maybe not enough to not move to discovery. I just think reading this, you have to imagine, we’re splitting hairs here in a way that’s unnecessary and perhaps indicative that an antitrust case is not in the cards.

Brad Thorson (38:50): I found myself very quickly, just in skimming these, disagreeing with Particle’s definition of payvider. And it really skewed my reading of the rest of the responses. I found what Epic was writing around market definition to be far more compelling. And so the rest of their answers, I think I gave them a lot more credit. But I’m gonna be very interested to see what the decision around discovery is, because there are some redacted portions, maybe there’s some absolute bangers in there and we’ll find out about it. But I just thought that the definition of payvider on Particle’s side was particularly weak.

Pryce (39:26): People are gonna wanna know, what is the Health API Guy take?

Brendan Keeler (39:29): What we think is right or wrong about these topics, as you heard me digress and go off on a side quest, is totally distinct from antitrust law. We’re not lawyers, but I really like antitrust law. And the bar is really high for it, and market definition has always been the challenge. This weird take-home exam and phase one is all because Judge Buchwald has been skeptical of the product market. And that’s not good for Particle. Reading these responses, I don’t see it getting better. So my guess about the way the case goes is that she allows for summary judgment against the antitrust claim, and at least Epic gets a shot via that to dismiss that count. There is one remaining claim, and Particle makes a strong and compelling case for prejudice, if that was to be dismissed, of this tortious interference on their contracts with one of their clients, which is a separate claim that’s really not part of this whole phase one. So I imagine maybe a motion for summary judgment being allowed and then progressing to a discovery that’s focused around that claim, which is lower damages and just isn’t the big cut that I think Quinn Emanuel and Particle were hoping to get. But we shall see.

Pryce (40:46): Stay tuned. Maybe it’ll go to game seven.

Brad Thorson (40:50): Gentlemen, Knicks in four.

Brendan Keeler (40:52): Spurs, let’s go, Spurs. There we go.

Pryce (40:55): Go baby. We’re down, but we’re not out, and we’re very optimistic.

Brad Thorson (41:02): Big game tonight, Pryce.

Brendan Keeler (41:03): We love an underdog in both this court case and the Spurs. So see you all next time.

Pryce (41:07): Thanks all.

Brad Thorson (41:12): See you guys.

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 generally patient summaries or discharge summaries, things like that. Those networks are being used to exchange a much higher volume of documents for the purpose of generally transitions of care. All of these networks. pretty much only allow treatment use cases. Like you have to be a provider querying other providers to get data. TEFCA has recently introduced that individual access service use case that I talked about and they all have trouble introducing other use cases because it’s hard to trust, know, thousands of nodes on a network that you don’t actually have agreements with, business agreements with. And so I guess TEFCA has seen a lot of adoption in that Athena’s on TEFCA Epic sites are on TEFCA, if not completely, they’re trying to roll out to make sure their endpoints are available. Who else is already on there?

Brendan Keeler (04:41): So MEDITECH, Athena, ECW, Epic are all on there. Oracle has a few sites, right? Because they gave them a QHIN later of the 11 QHINs that are participating. so, yeah, think Lukewarm, the measure metric, there’s always like, what’s our bar for success is the way I think about it. And...

Brendan Keeler (05:01): Relative to Carequality, it’s like, look, the numbers, just doesn’t match up. But exchange in a decentralized network is exponential in terms of growth, because then the number of connections goes up exponentially with each new participant in terms of linking between them all. And so I think it’s like, okay, is that successful? Well, by treatment, if you’re measuring against Carequality it’s like, well,

Brendan Keeler (05:26): It’s not even close, but should we be or should we be looking at it as a net new network because it’s facilitating Individual Access Services, which was zero before. And so by that measure, you might say, wow, what a stunning success because it’s doing something at scale with some problems that we can talk about. So the measure and metric, think I’m putting it relative to where it was two years ago, which was zero.

Pryce (05:41): Yeah. Right. Right. Well, and you know, it’s funny, we had the same conversation just on the last podcast towards the end. said something about the CMS Health Tech Ecosystem and is it going to be successful and how much, how much work are they getting done? And Brendan was like, they’ve gotten so much work done considering it’s only been nine months. So that’s a good point, Brendan. You know, if I was building something, building an electronic health record and I wanted to connect to a nationwide network to pull charts. TEFCA might not be my first, might not be the first entity that I connect to, but even the fact that it’s going to exist and hopefully supersede Carequality and in use cases is a great success. I guess I’m just saying it’s not quite like the king of electronic health data exchange. And particularly, guess something that sours how I feel about it is that I have a terrible Individual Access Services experience every time I use a little bit per implementer. know, there’s from an IAS provider perspective, there are these different companies that have built mechanisms for you to authenticate that you are yourself, usually using like a CLEAR or an ID.me, which is IAL2 level authentication, saying I’m looking at your face and I’m looking at a government issued ID and I say, this must be Pryce. And then you can send a query to your QHIN that says, go look for Pryce’s charts. But man, get, mean, I’ve got a Athena based doctor down the road that doesn’t respond to my IAS queries. You know, when I go to the network and say, I need my charts for, you know, for my Oura app. Like I want it to be tied to my sleep score and things like that. I never see the North San Antonio Healthcare Associates. And I don’t know if that’s Flexpa’s fault. Just that’s an example of an IAS implementer. I don’t know if it’s their QHIN’s fault. I don’t know if it’s Athena’s fault. I don’t know if it’s my site on Athena’s fault. Like if it’s my particular provider who just, who’s like, ⁓ our council doesn’t like the idea of that. Don’t turn it on for us. And so. Yeah, it’s hard. Again, like as far as success goes, I’ve never built a trusted exchange framework and common agreement. So props to the folks who’ve done it. But, ⁓ you know, it’s, it’s been disappointing so far for me. And I’m like wanting to know how to push the ball forward.

Brendan Keeler (08:06): Yeah, Brad, what about you? You tried it out?

Brad (08:07): Well, as I think all the listeners should know, whenever there is a new opportunity to test one of these, I think I’m one of Brendan’s trusted exchange dummies. ⁓ You got guinea pigs? Most, I mean, the weird part about this for me is my healthcare for the past, let’s call it nearly a decade, has been at two health systems, the random third one in there that we

Brendan Keeler (08:18): Guinea pigs if you will. You’re my guinea pig.

Brad (08:31): Don’t need to talk about. So the request pattern for me is like pretty straightforward. And if I use somebody, you know, if I test somebody who’s also using G 10 APIs, then I can just log and like I get everything. Honestly, this isn’t really a critique of the network, but if I had to critique. One part about my experience is my problem list or my conditions just never gets cleaned up. And so for somebody, I’m not living with any, aside from being morbidly obese and every sort of after visit summary, I’m not, yeah, it says I have a torn calf that happened six years ago and why has nobody taken that off? I don’t need to access, I don’t need IAS to really change anything about my life, but it is frustrating as a patient. to suddenly be able to see everything and feel like, it almost makes me feel like I have less agency, which I know is, that’s like a tangent that we don’t necessarily need to go down. I have lived in the same city, I have gotten the same care from the same set of providers for a really long time. I hear stats about people not moving more than two zip codes away from where they were born or like not a super mobile population. I sometimes come back to like, how big is the problem that we’re solving or can we define specific use cases that house an actual documentation or transparency problem instead of saying, can we get 7 billion records exchanged across TEFCA?

Brendan Keeler (09:57): If you look at other network based problem sets like payments, there are ubiquitous networks like cash, right? Cash is a ubiquitous network in terms of being able to go and bring it to most places historically and use it. And even with the advent of check and credit card and other technologies, cash still prevail because of ubiquity, flexibility, et cetera. And so as we think about Carequality, Like will it be sunset or something? Well, there’s ubiquity to it. So maybe it persists. As we think about prior patient access networks, you hinted at one Brad that I think we should illustrate further is that Individual Access Services is the fifth generation of us attempting to give patients access to their data. And so it started with HIPAA in terms of the patient right of access, a very manual but ubiquitous process that I can go. satutorily with a statutory right and request my information from any hospital. That is ubiquitous, It applies to all covered entities.

Pryce (10:57): But that was like a right, not a process. It was ubiquitous.

Brendan Keeler (11:00): but it establishes a ubiquitous, sans HIPAA in that right, you go to your hospital, they’re like, hey, get the hell out of here. And so it’s not ubiquitous. So it built a ubiquitous, albeit manual network like cash. And so it’s persistent. It’s still the fallback. We then had View Download Transmit, which for all certified EHRs, they needed to give a capability in the patient portal to download a CDA document. And so, not as ubiquitous, but pretty far along the pattern in terms of certified EHRs are a lot of, are many, many different providers. And as a result, scrapers built, know, HumanAPI and other scrapers built the capabilities to reach in there and built a network, right? A network to allow for programmatic access to those CDA documents. Pryce, your hand was up. So you got a thought, I think.

Pryce (11:45): I just gonna say, I just wanted to clarify, I think View Download Transmit was like Meaningful Use or something. So what era are we talking about? Like 2015-ish or something? Okay. And then the output, just to be clear to the layperson, I mean even myself, because I’m not an engineer, a CDA is like an XML formatted blurb of.

Brendan Keeler (11:53): 2012, yeah, 2010.

Pryce (12:10): confusing information to the layperson. And so it was available programmatically, but maybe not immediately usable unless you were using one of these aggregators like ⁓ OneRecord who could figure out how to make it usable for you.

Brendan Keeler (12:23): The hypothetical benefit was that CDAs also were both computable formats and also with a renderer, you know, could be rendered visually. Like that was one of their benefits and like why people liked that format. so hypothetically, was beneficial in that way. The bigger barriers were typing in your username and password to individual patient portals. And so...

Pryce (12:43): which is authentication. That’s proving that you are who you’re saying you are. If I say I’m Pryce and I know Pryce’s username and I know Pryce’s password, then the system just has to assume that I am Pryce.

Brendan Keeler (12:55): Yep. And so that persisted, we assumed that the problem with that generation, the CDA and View Download Transmit generation of patient access was the format that it wasn’t programmatic enough, that it wasn’t an API. And so with Meaningful Use 3, but really the Cures Act, we said, okay, certified EHRs need to make available APIs with core clinical data that can be surfaced to third-party applications. So we assumed from a regulatory and policy perspective,

Brendan Keeler (13:22): that would fix it. That was the big problem. And then people aggregated those APIs, notably 1up Health, notably b.well notably OneRecord were some of the big push people to push that. Yep. And we encountered another problem. What’s that problem? Username and password is, for Brad, is not challenging. But for some populations, if you have chronic illnesses, if you’ve moved around a lot, you might have a lot of portals. You may not have activated those portals with username and password.

Brad (13:49): Yeah, the activation. I know you did. There’s a great piece, if you want to know how psychotic Brendan is, of him signing up for every MyChart. And the one health system that is not in New York City that I have records at has this like insane, you have to get a PIN code. And they mailed me a postcard and I didn’t get that postcard fast enough for the... I was like, why am I going through a three month process to create a username and password for a health chart that like I don’t care about? And I will say I can now get access to those records. So that’s positive. Thank you, TEFCA.

Brendan Keeler (14:20): What is security if not a three month friction-filled process? The bad guys can’t get in either.

Brad (14:26): No? You better have the key to my mailbox. You better have... It was wild. Yeah.

Brendan Keeler (14:32): But that was the barrier perceived by our regulators, ⁓ Kristen Valdez of b.well has termed it portalitis, right? For these frequent flyer chronic illness or sickos like myself that go and sign up for all the portals. by whatever means, whatever it means if you’ve gotten so many portals, it takes a lot of time to log into the 57 portals. Literally it takes me half an hour. And so they,

Brad (14:47): That’s a different form of chronic illness.

Brendan Keeler (14:59): Stefka Individual Access Services supersedes a fairly ubiquitous capability, the Cures Act G10 APIs with less friction-filled experience where you take the CLEAR, ID.me or Persona, ID proofing, selfie and such, and then can hypothetically pull from the network, the problem being it’s not at the same ubiquity. And so I think of it like Apple Pay or Google Pay where you’re like, sweet, I can use that sometimes, but. I can’t use it all the time. And so we still fall back to check. We still fall back to ACH. We still fall back to cash when we want to get ubiquity.

Brad (15:35): Question for you guys. So I get excited about new capabilities and diagnostic imaging. one part about getting my records when I had a weird illness, I had to take a CD into NYU for them to put my imaging and then mail that off to somebody else, which was like,

Brad (15:56): I mean, I figured out how to do it, but like, had I not had time to take off work, those images would have never gotten out of NYU. Is the, is ONC, and maybe we don’t know the answer, but when ONC considers new data types to be exchanged, is TEFCA the default network that they’re gonna use or will we establish different networks?

Pryce (16:16): I think it remains to be seen, right? mean, like, so the CMS put out an RFI for diagnostic imaging this year.

Brendan Keeler (16:21): It was the ONC, actually.

Pryce (16:22): It was the ONC. Okay. did they say we should do this on TEFCA? No. And if they, if they were to try to do that, it would probably require a lot of new technology because right now TEFCA is largely CDA and XCPD still, which is

Pryce (16:37): HL7 version 3, FHIR sort of HL7 version 4.

Brendan Keeler (16:40): the history here, there’s a couple commingled factors that make it challenging. So diagnostic images aren’t in the EHR typically, right? They’re in the PACS system, which is unregulated. So that’s challenge one is like, how do you get Sectra and AGFA and all these other PACS to build the capabilities and to play in the ecosystem when they’re not regulated? That’s challenge one. Challenge two is these are big. files, right? Terabytes potentially, depending on the type of diagnostic image that’s produced, let alone video for like endoscopies and such. Three is, you know, like what are we doing matters? Like, because just surfacing in the USCDI data sets as this is a core piece of clinical data. And then it’s like, are we doing patient access to that data? Are we doing B2B networked exchange? Are we just making it available for point solutions? Like there’s different problem sets to be solved. And so the RFI was inclusive. It was sort of like a poking around at all of them. was like, all right, how would we do it for provider to provider? How would we do it for patient access? The nice thing for patient access is that brilliant HL7 geniuses, particularly Josh Mandel have already done like an implementation guide and planned out how you do it for that problem set. Like what are the. ways the EHR would interact with the PACs. For B2B, what’s interesting is there’s like 30 different standards. So like there’s been many different cuts at Wado RS over DICOM or all these different obscure acronyms for like how could you translate it or transmit it rather? And no one, we a consensus. There was even in CareQuality and Commonwell implementation guides for diagnostic image exchange. And they tried to engage different vendors like AGFA and Ambra and Life Image. they were like, well, why would we do this? We want to do our proprietary private networks for diagnostic image exchange. And so it’s challenging. It’s challenging for all those reasons, but precedent, international precedent shows it’s possible. So the Netherlands does diagnostic image exchange. They use what’s called XDS-I. So basically, an extension of the technologies used for Carequality and, um, CDA exchange. And they do it, they do it, uh, not ubiquitously, in read like regional health information exchanges, they, they have what’s called TWIIN, um, which is a national initiative and they’re, they’re making tremendous progress there. So just about picking it, incentivizing it and getting people to play along.

Pryce (19:05): You know, it does matter what the use, the use is here. Like, like we think, okay, so why are images not flying across this network as well? And then my first thought is kind of like, well, generally the moment an image is taken, it’s for, it’s diagnostic imaging. Then a radiologist who is affiliated with where the image was taken, interprets the image and writes all about it. And then it’s back in the EHR. So in a lot of ways you could say like, well, the juice, the value of the image has already been extracted and somebody should have access to that information via CDA exchange or, or FHIR APIs things like that. Of course, I guess it makes sense that a lot of physicians or radiologists or whomever would say, well, I would actually like to see the image myself as well and come to my own conclusions. Is that what’s happening here? Is that why people are always like, I want the image instead of just the, diagnostic study, is sort of the outcome of what we thought of the image.

Brendan Keeler (19:57): Brad, you look like you have a thought.

Brad (19:58): I would guess that there’s this is a trust issue and like whether or not I think somebody read the diagnostic study correctly. My opinion is slightly tinged by like, has the ability to get those records between systems, the diagnostic studies improved over the last five years when I had to deliver a CD to the hospital or?

Pryce (20:20): you’re saying like, would it be more likely nowadays? Yeah, yeah, yeah. Would it be more likely nowadays that the doctor to whom you’re going next is like, well, I already get the gist of what the image, what that MRI said or, yeah.

Brad (20:22): Like has it changed? Yeah.

Brendan Keeler (20:32): There’s just a lot of workflows where it’s valuable. A second opinion is just an obvious one where it’s like, think this radiologist is s**t, let me go down the street and suddenly you gotta go get another MRI or something, that stinks. It could be like you get injured again, right, you break your leg again, and they’re like, okay, well, let’s go see what the break originally was last time. looking at the...

Brendan Keeler (20:55): the radiologist report might not give the information to the new radiologist of like, okay, what happened here? How did he all like there? And then there’s value to these diagnostic images, right? If you could build a big data set, you could start to do nifty things about, you know, with radio AI radiologists and things like that. So there’s a variety of reasons that yes, the, the diagnostic reports that are produced from the, these images. are transmitted or should be transmitted at least, but still there’s voracious demand to understand and see the actual raw images for reinterpretation or different reasons.

Pryce (21:31): So to build on this, we’re saying we have is live. Trust Exchange framework has tens of thousands of hospitals on it, and you can send a query up to a QHIN that says I’m looking for Pryce. He has an appointment with me tomorrow. then queries go out to all the other QHINs that try to locate me based on my demographics and my identity, not based on some sort of universal identifier. and then notify, not yet, not until I get my imperial chain code, Star Wars reference. ⁓ great weekend, just saw the Mandalorian and Grogu last night. at first, really tough code was like, okay, covered entities are going to exchange data with covered entities and they will authenticate against each other.

Brad (21:55): Not yet.

Brendan Keeler (22:01): It’s a good weekend for that. It’s a good weekend for that.

Pryce (22:15): you will know that it is Hopkins making the query when Hopkins makes the query. And then the authorization, the next step authentication is, I know the server making the query authentication or authorization? The second Z there is like, do they have permission to access this data? I believe they are who they say they are. And now what data do they have access to permission or permission to access? And by and large, you know, providers should have access to clinical data when they’re treating someone and and the whole chart except for maybe behavioral health information would be exchanged so long as patients opted in and things like that. But we’re talking about how using the same framework for multiple use cases can be challenging. How do you implement this if it’s a slightly different use case? And so with Individual Access Services, we see an interesting debate happening. I guess I’m not sure the history of this debate in TEFCA, but I can tell you it’s certainly happening. or people are thinking about it lot with regards to the CMS HealthTech ecosystem and CMS Aligned Networks. When we do Individual Access Services, like I said, I might take an app that’s gonna help me query TEFCA for my records and it will use CLEAR to verify that I am who I say that I am. And it’ll go off and query the networks, the QHINs and say, it’s for sure Pryce looking at his phone. He wants to give his data to Oura. because he is an Oura user and he wants to allow them access to his charts at his Athena PCP. The question then is, okay, I’ve authenticated that I am who I say I am. Typically, I would then need to authorize some sort of release of data from the system that actually has it. So just as an example, when you go to sign in to Instagram and then it says, do you want to sign in using Google? You click yes, then it takes you to Google and Google says, do you want Instagram to have access to your name, your birthday, your email, et cetera? And you say yes. And that is you authorizing. You’ve authenticated that you are, you say you are, and you authorize the exchange of data for a certain time period or for a certain scope of information. And right now, That’s not exactly happening with TEFCA. The author is, or the authentication is saying, okay, this is definitely Pryce return his chart. And only Epic I think is at the moment on TEFCA then redirecting. this is pissing a lot of people off because they think it’s Epic sort of blocking the liquidity of data. But Epic then says,

Brendan Keeler (24:36): There’s literally, let’s be clear, there’s literally an antitrust lawsuit by the AADJ against them for alleging that. yeah, I would say some people think it.

Pryce (24:42): Well, it’s for a lot of things. Yeah, I could go on about that for a minute too. so yeah, it’s just like, is Epic right or wrong by saying, well, okay, I believe that it’s Pryce on the line. Now I want him to log in and tell me, here’s your records from Hopkins, you know, which uses Epic. How long do you, you do you want us to give them your allergies, your meds? Do you want to give us all this? How long do you want them to have access to it? And so in a way, Epic thinks that they’re being pragmatic and, and, ⁓ usefully, I guess, limiting the, unlimited exchange of healthcare data without my permission. But in a lot of, in a lot of ways, people are like, no, if Pryce took his picture and he asked to fetch his records, he wants the whole thing. And so authentication and authorization at the moment, they’re hard to implement separately because people wanted them to be jammed together, but we’re doing this on rails, you know, that didn’t account for this kind of very nuanced piece of the workflow. So yeah, where have we landed with that, Brendan? Maybe you could tell us like, is there an official recommendation from TEFCA or from the CMS Health Tech Ecosystem as to how we’re handling that for Individual Access Services?

Brendan Keeler (25:53): Yeah, a couple of things I’ll layer in. Epic alone is doing the FHIR-based flow, right? So when data is retrieved for Individual Access Services, it’s going through and doing this, what’s called an XCPD first, right? Which is not FHIR. It’s a patient search to all the QHINs. It says, hey, do you have Pryce? Do you have Brendan? Do you have Brad? Here’s the identity token that they proves that they proofed with CLEAR, proofed with ID.me, proofed with Persona. And then those different QHINs say, yup, here’s where they’ve been seen. So for me, it’s like 50 Epic sites, one ECW site, some random HIE that I’ve never been seen at, which I don’t know why it’s happening. And anyway, and then they go and they can do one of two things. They can either go and do a CDA retrieval, if that’s what’s supported, or they can go and do the FHIR flow. And so for all the other Individual Access Services implementations thus far that we’re aware of, it’s been, they just said, okay, well, if you include Individual Access in the header of your CDA retrieval, we’ll give you back the CDA that we give for treatment. So it’s a very blunt old school approach, but probably more simplistic to implement for than full new FHIR flows.

Pryce (27:00): Well, and admittedly, 95, 98, 99 % of the people who are taking a picture of themselves on CLEAR to fetch their patient records probably just want the whole patient record to come back. They’re not looking to then talk to Epic and say, yeah, it was me. Here are the pieces that I want. But go on.

Brendan Keeler (27:15): I don’t, does the end user care? Like they care that the job to be done that they’re doing is done is the way I think about it. Does the app care? Well, I think there’s a lot of people out there that would say, well, we need to get to a FHIR, a new FHIR native network. And in that way, the only person pushing on that right now, thus far is Epic. so props to them. We have to give... what was it? S**t sandwich, right? Like the positive, the negative and the positive. So the,

Pryce (27:20): Right, that’s what I’m saying.

Brendan Keeler (27:39): The s**t part, the middle part is authentication and authorization. With the CDA flow, you’ve already identified proof, great. You got authorization, you got authentication baked in, you pull those documents, have fun. For the Epic flow, from a privacy perspective, from a security perspective, they’re saying on behalf of their health systems, we need to have a layer of authentication and then the authorization to prevent security breaches is the argument that’s been posited. Until they can get government relief from the OIG saying, hey, until if we release this pattern, we’re not gonna be liable for a HIPAA breach, then they have been pushed saying, we don’t wanna do this because there’s no upside. What is the upside to doing this except somebody suing us when a breach happens in this pattern? And make no mistake, people sue about these things all the time, all the time. And HIPAA doesn’t afford the right private action, but they find patterns and ways, right? We see this with the lawsuit where there’s all these class actions that are brewing. And so there’s a reality that people need to at least understand that that is the math for, you know, Cleveland Clinic’s general counsel. The ship is sailing there though, because ⁓ the CMS Health Tech Ecosystem. All these trends are saying we gotta get rid of authentication. Optically, it’s not looking good for Epic. So authentication is at least consolidating down to MyChart Central, right? One login for Epic and probably looking to get rid of it at some point later this year in the future. so authentication goes away, but authorization is interesting because it’s like, well, if I have authorization, and it’s on the health system side, then I can do nifty things like deal with caretakers or deal with other proxy situations so that Pryce, after he’s identity-approved and starts to pull records, could then select and say, okay, I want it for my son or for my mother or somebody, you know, a proxy situation. And so that could be accommodated in a slightly more straightforward fashion with hospital-side authorization. But I also think the ship is sailed there where people are like, well, we want authorization outside of the EHR, outside of the provider, which means that we have to go reinvent something to deal with proxies.

Pryce (29:53): Also really quickly, Epic actually does enable health systems to turn on, either respond directly to the IAS query or ask for authorization from the patient by not only requiring the IAL to OIDC token from Clear, but also get them to log in and say which part. Those health systems, those Epic using health systems can allow either path. And to your point, Brendan, all of their, you know, regulatory compliance and legal officers are saying, make it as hard as possible to access this data unless it’s Brendan, unless he knows he remembers his password and his username, things like that. So it’s interesting, like they can develop something, but they’re not implementing it. It’s these providers who are implementing it the way that they want to implement it. Brad, did you have something to say?

Brad (30:37): I was gonna say for the lay listener, like we’re talking about whether or not consumers want GDPR cookie banners, like do you want to accept all, do you want to go through and experience wise, I think as long as IAS is an accepted paradigm, most patients, based on other industries, most patients are just gonna take the whole record.

Brad (31:00): if they can get it and not be discerning about it. this is a can of worms that I don’t think we should open, but that leads to likely a lot of leakage of that health data. It’s going to entities that are not covered by HIPAA. I mean, Equifax lost all of my information a long time ago, so I’m constantly locked down. But we’re going to see... we’re probably going to start having to go through a CLEAR identity process for like billing purposes because the chance for fraudulent billing with our health records is going to explode dramatically. This is just law of unintended consequences, which is a hard thing to open towards the end of our time that we can talk together. I do think, regardless of what businesses try to do, patients are going to look for the easiest solution. And the easiest solution is dump everything and let let the vendor who’s getting this data figure out what to do with it.

Brendan Keeler (31:55): Yeah. And it’s why, look, I think of everything in trade-offs. it’s like all these architectures we’re talking about where author, you know, where all legalized, processized, technologies, technologize it. you know, you think about the trade-offs of like, what does it mean to put authorization on the health system side? What does it mean to put it on the credential service provider, like clear and what would it mean to put it on the app? And there’s just trade-offs that are very clear about those architectures. And we have to consider, okay, what are we, what are we optimizing for?

Brad (32:00): Legalize it.

Brendan Keeler (32:22): like we would in a product management. It’s like a product management hat of for this national product, this national architecture, what are the trade-offs? And so the trade-off, the biggest trade-off with app-owned authorization is you no longer have separation of church and state, right? There’s, have to control and constrain the behaviors of the app by legal, by legal terms, by saying, you need to, you’ve certified the CARIN code of conduct. You’ve been certified by this group. You’ve signed this thing. Whereas if another entity, CLEAR or ID.me to own authorization or the health system, then suddenly, you know, the vector for abuse is mitigated by separation of who is asserting something and who has certain prerogatives.

Brendan Keeler (33:07): It seems like we’re choosing to move it to the app layer and that’s fine. We just need to be really, really honest with there’s going to be apps that want to have a different, there are good apps today, like B.well or like Fasten right? That are good and honest and think, think thoughtfully about how they’re treating patients. There are less scrupulous apps that will come and how do we constrain them from abusing it when their intention. and their goals differ from the patient’s. We can do it with legalese, can do it with certifications, we can do it with all those behavioral things, but it removes the technological barriers towards abuse.

Brad (33:44): Well, it’s Memorial Day weekend. We’ve told you a lot about TEFCA, but what’s everybody putting on their burger this weekend?

Pryce (33:52): Ooh, I think I still need to buy sausages and tortillas because that’s how we roll down here in San Antonio. A little sausage wrap.

Brendan Keeler (33:57): Dang, we gotta get down there for a team trip. That’s what’s up.

Brendan Keeler (34:01): I’m gonna go, I’m doing it Dutch style, I’m gonna do mayonnaise on my burger. Just kidding.

Brad (34:05): What?

Pryce (34:07): Is that Dutch?

Brendan Keeler (34:08) But anyway, no just kidding, I’m not a sicko, I’m not a sociopath, at least in that facet of my life. alright, well have a great Memorial Day. If you’re interested in working with this crew on TEFCA, on IAS, on all the good things, please reach out and we’ll talk to y’all later.

Make sure to follow and listen to The Information Exchange on the podcast app of your choice! For instance, you can find the Spotify version here.

The stars have aligned. The crew is back, full strength and four-deep, with (somehow) no one traveling, sick, or on a plane. We covered some choice material pondering the nature of not just Epic, but systems of record, antitrust, information blocking, and competition writ large. Some highlights:

* Judy did Freakonomics and Katie Couric (after Acquired and Forbes in the past year). We dig into why a company that spent 40 years letting the work speak for itself is suddenly hiring marketing people and putting its 82-year-old founder in front of podcast mics.

* API counts don’t measure openness. Why athenahealth’s developer experience runs circles around Epic’s, and why information blocking changes the co-opetition math for every system of record vendor.

* Epic Cinematic Litigative Universe mini-tour: Particle sits waiting for a potential motion for summary judgment in a May of rapid litigative developments. Plus the SSNIP test and why antitrust law is structurally a bad fit for systems of record.

* CMS announced electronic prior auth as a new pledge category. The pledging networks (b.well, CommonWell, eHealth Exchange, Kno2) are all clinical data networks. Were clearinghouses snubbed? Why CMS just tipped the X12/FHIR scales with seven months left on CMS-0057.

Also: a fashion heat check from our local New York correspondent, Patagonia as Epic’s spirit animal, and the case for Judy on Joe Rogan

Relevant Articles

* How Leeds avoided relegation: We’re happy for Brad. MOT.

* Judy Gets Her Freakonomics On: Discussion of the Freakonomics interview and the insights it brings into Epic

* Katie’s one-on-one with Judy Faulkner of Epic Systems: A longer interview by the famous journalist that pushed on Judy a bit harder

* Organic Beer by Patagonia Provisions: I can’t believe this exists. Please comment on quality if you’ve tried.

* Epic Opens the Door Wider for Developers: A post from last September about Epic’s incremental progress in changing how they treat developers

* The Prodigal EHR: A previous article about how athenahealth leads the pack in terms of developer experience

* The Iceberg Fallacy: Some further discussion of the cool developer experience and features athenahealth is releasing beyond the basics

* AADJ v. Epic: Antitrust case referenced briefly in the episode. Epic’s motion to dismiss was filed on Friday, as mentioned.

* 2025 EHR KLAS Report: Fierce Healthcare’s summary of the annual EHR research, which mentions how many Oracle Health customers want to switch but can’t. Mentioned in the article in reference to the SSNIP test.

* Epic Litigative Universe: Prior article explaining all the lawsuits against Epic.

* Electronic Prior Authorization in CMS Health Tech Ecosystem: Announcement of the new category and early adopters

* CMS-0062: An Intra-Agency Cold War Goes Hot: Previous discussion of how prior authorization sits in the middle of the Venn diagram between administrative and clinical

Chapters

* Intro and Travel Catch-Up (0:00 – 0:44): The crew reunites after time apart and trades notes from Palm Springs, the NBA playoffs, and a trip across the pond.

* Judy’s Media Tour (0:44 – 5:16): Judy Faulkner’s recent Freakonomics and Katie Couric interviews mark a sharp break from Epic’s historical posture of silence, raising questions about what’s driving the shift.

* Epic Projects Outward (5:16 – 7:20): Why a company that long relied on word-of-mouth is suddenly investing in external messaging, and who inside (or outside) the company might be pushing it.

* APIs, Co-opetition, and Athena (7:20 – 12:13): Counting APIs is the wrong measure of openness. A look at what real developer-friendliness looks like and why information blocking changes the economic calculus for system-of-record vendors.

* Defense or Real Change? (12:13 – 16:27): Are Epic’s recent openness efforts durable, or a defensive crouch that ends if the lawsuits do? The crew debates how much of the company’s posture toward outside developers is cultural versus strategic.

* Boomerangs and the Chief Meme Officer (16:27 – 18:16): Predictions on where Epic’s external-facing energy goes from here, plus a modest proposal for a certain alumnus to make a triumphant return.

* The Epic Cinematic Litigative Universe (18:16 – 23:11): A tour of the active litigation against Epic, with attention to why antitrust law is poorly suited to systems of record and where information blocking gives plaintiffs more to work with.

* The New Prior Auth Pledge Category (23:12 – 27:22): CMS adds electronic prior authorization to the Health Tech Ecosystem pledge structure, with conspicuous decisions about who’s invited and who’s left out.

* Administrative vs. Clinical Rails (27:22 – 29:12): Prior auth has always lived at the intersection of two standards worlds, and the new pledge structure tips the scales toward one. The implications, with the CMS-0057 deadline approaching fast.

* The Clipboard Is Still Breathing (29:12 – 31:50): A reality check on whether any of this regulatory motion is reaching actual patients yet, and a debate over how to measure progress when the deliverables are rules rather than experiences.

Transcript

We ran the transcript through an LLM to smooth it out. So it’s a rough approximation of the conversation (and in many cases significantly clearer than our rambling), but notably diverges from the word-by-word blows quite a bit.

Pryce (00:00): All right. Welcome back everyone to this not-a-podcast that we call The Information Exchange. We four are glad to be back together. It’s been a long time since we’ve all been in town. We had travel to Palm Springs, which was really rough. Brad and I, Brendan and I had to, you know, suck it up and go enjoy Southern California. And I’ve been busy with, you know, this like, it’s really hard to watch all the Spurs games because hopefully by the time we release this, they’ll be in the Western Conference finals. So, and Brad, with your football team behind you, was in England for a little while checking out the EPL.

Brad (00:33): For all of our big audience in Leeds. They’re very excited to see this.

Pryce (00:37): Yeah, exactly. Shout out. Shout out to Leeds United. Well, Brad, why don’t you get us kicked off? What’s first on our agenda today?

Brad (00:44): Well, you know, I was in England, so I missed some things and I came back to it’s been a flurry of lawsuits at the beginning of the year as Brendan has hopefully covered. Seems like Epic is active in the courts and now they’re active in our newsrooms. We got podcasts, Freakonomics with Judy and then Katie Couric, a former coworker of mine. If you want to hear that story. Yahoo and AOL merged. We don’t need to go into that section of my life. But I did ride the elevator with her one time, and she was very lovely. Yeah, Judy’s out there at the young age of, am I right in saying 79? Does anybody know for certain?

Ryan Tucker (01:18): I think they said 82 on the interview.

Brad (01:20): 82, oh man. Well, one thing I’ll say is she was at HIMSS in a leather jacket and she looked sick. So 82 looks good on Judy. And she’s not slowing down. Maybe President is next.

Brendan Keeler (01:33): Are leather jackets, I’m not trendy as evidenced with Waldo here, are leather jackets in? Is that a trendy look?

Brad (01:38): Well, though, yeah.

Pryce (01:44): I think if you’re rich enough...

Brad (01:45): Did leather jackets ever go out? It’s just that you have to have the vibe. Yeah.

Pryce (01:49): Meaner, yeah.

Brendan Keeler (01:50): New York Man is the trendy one of the four of us. We’ll take that word. Ryan, what do you think? Did you see any of those interviews?

Ryan Tucker (01:57): Yeah, I watched the Katie Couric one. You know, the whole time we were at Epic, very reserved in terms of anything external facing. Judy did meet with folks internally quite a bit and would regularly talk at our monthly staff meetings. And so we heard from her a lot, but there was never really anything publicly facing. Now that all these lawsuits have started happening, maybe some perceptions that were a little brighter have started to turn. It’s interesting that she starts to speak up. Maybe that’s the more cynical side of me talking there. She, in my opinion, does not have the best media training. I think the lack of like the past 30 or 40 years of doing any public-facing interviews is quite evident. Katie Couric was like very amicable to start. She was even trying to draw some lines between like her path and like the difficulty of being a woman in an industry where it’s really surrounded by men and how they’ve kind of both succeeded. And so she was trying to like maybe find some camaraderie there that felt pretty flat. And then my favorite portion of the interview was she started to talk about like Epic’s culture and it was a true like s**t sandwich tactic by Katie Couric where she talked very highly of the campus, of the art around the campus. And then she mixed in, it seems to be a bit like Lumon on steroids, which if you all have watched Severance is like not at all a compliment, but I don’t think Judy got the reference at all.

Brendan Keeler (03:35): Just blew right by it and there were laughs and I was like wait a minute. And I think that’s something worth noting. Freakonomics was kind of a puff piece, was really positive. Katie Couric one, definitely she dug in, but like with that zinger but also some questions.

Ryan Tucker (03:53): Yeah, I do wish she followed up a little bit more, like held her a little more to the fire, but also she’s at the Epic conference. I wouldn’t be able to do that personally. There’s also like definitely some analogy to be drawn there about Lumon internally, the Innies versus the outside world. You might see Lumon as kind of a corporate business that’s succeeding. I do think there’s tales to be told about Epic there. So yeah, it’s just very interesting how this is all playing out, especially for someone who worked there for five years and there was nothing at all that would ever be put out like this during that time.

Brad (04:30): We have three former Innies right here.

Ryan Tucker (04:32): Yeah, exactly.

Brendan Keeler (04:34): Brainwashed.

Pryce (04:34): Yeah, what’s the opposite of severance again? Re-assimilation or something? That’s what we must have done.

Ryan Tucker (04:40): Yeah, yeah.

Brendan Keeler (04:40): Yeah. What I’ll say about it all is that they are changing, right? They’ve hired marketing people. They started to allow outsiders to come to UGM. They have somebody who’s like chief meme officer, not that title, but is running the restarted Twitter account and social media since last fall. So clearly something is changing. And then they’ve done, you know, some of the biggest podcasts in the industry, right? Katie Couric’s huge. Freakonomics is a household brand. And then they had acquired last spring. All they need is Joe Rogan and like, you know, we’re set.

Brad (05:16): Calling it here, Judy smoking a blunt on Joe Rogan. It’s gonna end health tech.

Brendan Keeler (05:20): It would be tremendous, break the internet. I mean, even on, I think it was the Couric interview, Katie said something to Judy like, hey, what’s changed for you recently? And she’s like, I never had to do these sorts of interviews. So I think she’s being pushed by maybe some of her policy people, maybe some of her marketing people to start to project outwards more. She’s done that Forbes interview a year ago. All of this to say is that they’re trying to actually shape their external opinion because they have strong belief in the good things that they’re doing in this world and the good things they’re doing for healthcare, and realizing that now with their posture in the industry, they need to project outward and influence those perceptions that are out there because otherwise the lawsuits continue to pile up and just the sentiment becomes a thing of its own, well, and its own snowball effect.

Pryce (06:09): When I worked at Epic from 2015 to barely 2017, you know, the theory was like, we let our work speak for itself. Our customers will speak highly about us, other customers. What more could you need, you know, in the way of marketing, especially because it’s not like you run a Super Bowl ad about your electronic health record. But it’s funny to think like, well, now that the sort of perspective on Epic, a perspective about Epic, has saturated the market. Everyone has heard of it. Everyone either has it or they’re being forced to move to it or they want to move to it or they hate it. And now it’s like, yeah, all of a sudden it’s like, well, word of mouth has kind of run its route in terms of a marketing strategy. And Brendan, you were saying maybe the internal team at Epic is pushing her to be more public. I was just thinking, customers are probably saying, listen, if we’re going to be an Epic shop, if Mayo Clinic is going to be an Epic shop, if Cleveland Clinic is going to be an Epic shop and the CMS is always banging on our door and et cetera, et cetera, we’re named in lawsuits because of data that was leaked through a nationwide trust framework, et cetera, et cetera, et cetera. Are those CIOs or those CEOs, you know, approaching Epic and saying like, you all got to get a handle on this.

Brendan Keeler (07:20): Okay, so we had Lumon in the Couric interview, and then in the Freakonomics interview, they’re like, we tried to find companies that were like Epic, and the only one that kept coming up was Patagonia. And I’m like, what? Patagonia.

Ryan Tucker (07:31): That’s like the totally opposite direction to me.

Brendan Keeler (07:34): Which kind of makes both food now and beer. They have beer in the beer aisle. And I’m like, this is a conglomerate. I didn’t know that, was diversifying it. I don’t think Epic’s doing any of these things. Because I would definitely try an Epic beer. I have no idea what it would be like. Digging into the interviews, there were some nuggets, particularly in the Freakonomics one, where it just showed how Judy and also Epic perceive themselves, right? She said something to the extent of, well, we’re interoperable. We make the most APIs, maybe more APIs. We look at all the APIs. We’ve got so many APIs and HL7 inputs and things like that. And I don’t think she’s wrong. I know she’s right, right? Because we have a little Claude Code script that pulls down all the APIs and stuff from the different EHR vendors, and it’s more. There’s more out there. More FHIR inputs and outputs and more HL7 interfaces than the other EHR vendors. But that’s not the point. The count of APIs and stuff is only one measure in the whole equation of are you friendly to third parties? Like, is that easy to use? Is the documentation there to support people in understanding what it really does and how it interacts with your software? Are you inviting people into the ecosystem? Is the water warm? And I think if Epic continues to believe that just the sheer count is enough to change the opinion from really the developer crowd, the venture capital crowd that has a strong hold over Washington, has a strong hold over this administration and a loud voice and influential voice, that’s got to change. They’ve started to with the Vendor Services Open@Epic conference, right? That got restarted last year and was a really good step to rebuilding a relationship with developers. But they have to do more. They have to continue to do more and push themselves for a model of co-opetition of inviting in what are sensibly competitors in many respects and competing with them, but also making the ecosystem where they can thrive. Like that’s hard. It’s hard to strike that balance, but it’s what other vendors do. It’s what athenahealth does quite well, right, as a comparison point.

Pryce (09:45): I was about to ask if you had an example. It’s hard within a capitalistic society for a company to say, let’s spend resources on helping other companies. But you think Athena does that well, what, just because of their API? It’s not like they, it’s not like.

Brendan Keeler (09:59): Yeah, yeah, and you don’t capture. Not just the API, the way they invite you in, right? The way that it’s documented, the way that they consistently have a change log that says what’s changed, that they have a partner program where they’re trying to engage with you. The challenge is that any company, maximal capture of revenue from a provider client or from any client as a software company is when they use all your products, right? If you’re selling a CRM, you can capture 100% of their CRM spend. If you are taking a cut of API transactions to a CRM third party, you’re only capturing a smaller portion of that. From a pure math perspective, system of record are biased towards building your own software and foreclosing third parties. That’s why things get bundled in every vertical. Information blocking changes that equation for EHRs, for healthcare. It’s a strong reason, beyond the morality and ethical reasons of co-opetition, to just lean towards co-opetition. Epic and other EHRs should take that to heart, lean into this idea of co-opetition because they’re still going to win a lot of these battles because the bundle still is appealing because defaults are appealing. You can sort of piece together some of the mentality in the responses from Judy. And she was even a little bit more pointed later in the interview for Freakonomics where they asked about antitrust. Are you worried about it? And she says, well, how can we possibly support all these, if there’s 50 developers for this dermatology app and there’s 10 of those apps, that’s 500 programmers, that’s a waste. And so from an economic efficiency standpoint, vertical integration, and it makes sense and there’s a math there that’s true, capitalism is inefficient. The inefficiency of redundancy and different things means there’s a lot of wasted effort, but the net outcome is better than a single top-down approach. And that tension surfaced in the interview. She has to realize, Epic has to realize, that the information blocking statute changes the equilibrium and the math here in a way that they should lean into and we see different platforms starting to lean into.

Brad (12:13): So. No disagreements. But I also think it’s tough to not look at, Judy is out here doing publicity for the first time since any of us have been alive. They’re also just facing an onslaught of lawsuits left and right, but they’re getting wins. None of us can read the tea leaves or know the future. I guess we can read the tea leaves and be wrong. How much of this feels like a defensive position that as they start to win in court, if they do start to win in court, they give up on these efforts of being more open? Put Judy’s interviews aside, does Vendor Services stop being important to them if they’re able to win in court?

Pryce (12:50): I want to take that because I have an opinion about Epic here. To Brendan’s point, the most functionality with regards to interoperability, they’re the first to release things when a regulation comes out that says they’re going to need to release this by this date. They’ll beat the deadline by a long shot. And yeah, they’re up against a bunch of folks who are angry that they’ve got a walled garden right now. I feel like the biggest mistake that Epic makes, I guess the thing that frustrates me the most, and Brendan, I think this speaks to why it feels like they’re not in co-opetition. It feels like they’re just exclusive. When you work at Epic, you just assume that everyone else doesn’t know what they’re talking about. And that’s the part of their culture, in my opinion. “Well, you don’t understand how Epic works. So you probably can’t help with my sepsis algorithm” or something like that. And when in fact the matter is like, if you just gave this other company a little bit of data, they would have a sepsis algorithm that far, you know, exceeds the capabilities of Epic, which I think was notoriously bad. And so anyway, that’s the frustration. It is not like the efforts that they put into enabling developers. It’s like the posture that they have towards those developers. It’s like always one of distrust, always one of, “You’re gonna mess this up.” And I don’t see that changing anytime soon.

Brendan Keeler (14:06): Epic is not a homogenous, a heterogeneous, large organization of 15,000 people and some people are being... So I struggle to be like assigned to any company of any size, those things. But in general, people’s greatest strengths also are their greatest weaknesses. And their paternalism in a pejorative sense is why they’re so...

Pryce (14:18): Well, it just got compared to Lumon. Yeah.

Brendan Keeler (14:33): Freaking effective at their installs and always hit their implementations as they come in opinionated and somehow train these 22 to 25 year olds to go and lead these really messy implementations that in every industry at system of record implementations take two years to install the ERP for the state of Kansas or something, and just delays and delays and whatever doesn’t happen. Their culture drives them to their success. But it also leads to, now that they’ve achieved that success, some real risks in terms of the antitrust posture, right? In terms of foreclosing competition, which by and large, I think antitrust law isn’t well suited to go after them, as we’ve discussed before. And that these cases, I think they’ll escape the antitrust ones. But information blocking, that’s a much more poignant, pointed risk for them. It really does tackle some of their weaknesses and forces them to say, what’s the new equilibrium here in terms of that co-opetition? And I see positive incremental change over the last two years in that regard, in terms of the Open@Epic vendor services, in terms of the Open@Epic conference. They just released 100 or something new Kit APIs in Vendor Services publicly. So there’s positive changes, but it’s not a one, do this one thing and solve, it’s a continued change of culture, of ways of engaging.

Pryce (15:57): It’s not a module you develop. It’s very operational and an operational drain. But yeah, that’s a really interesting point that you make. I was just looking at someone working in Cerner or Oracle earlier today and thinking, technology looks fine. Looks just as boring as every EHR. And it got me thinking, man, are the services at Epic just that much better? Like the install team, that much more effective than 50 people from Deloitte, and is that paternalism to your point, Brendan, really what keeps them focused and creating best practices and things like that.

Ryan Tucker (16:27): There’s a big difference between the anti-competitive behavior and the anti-openness to development. I think, like, Brad, you’re asking for a prediction of what will happen. I think the antitrust stuff, if that starts to die down, maybe we’ll see Judy be pulled back a little bit. Like the executive, like, you know, overall market facing side of the organization, I think that might start to shrink a little bit. The vendor services side, I’ve never personally felt that they were anti-being open to integration. It’s just they want to control the route that it takes. And so anything that ends up landing into their software, they very much want to control how that looks. And I think that comes from, Pryce, as you said, just skepticism when it comes to the other side’s development and what that might look like coming into their products. And I think they have some rights to want to control that too. I see them keeping with, especially if info blocking sticks around, which it looks like it will, sticking with the Vendor Services stuff, like more openness towards integration, not so much the marketing side. And also just before we get off of this topic, Epic. One thing you learn as you’re an employee there. Most folks will kind of go through it. There’s like a big calling around the two year mark and then the five year mark where people leave. Every once in a while you have a special case where somebody will actually come back and they call that a boomerang. And I just want to say, I think it’s a big missed opportunity if they did not reach out to our Waldo here for that chief meme officer. Did they ever contact you, Brendan, because that would be the opportunity for a Brendan boomerang that I think would make the most sense.

Brendan Keeler (18:10): You know, I have, I’ve not received anything yet. Maybe it’s gone to spam. We’ll have to see.

Ryan Tucker (18:14): Gotta check it. Gotta check it.

Brendan Keeler (18:16): In terms of tactically, Brad, the court cases, right, we are, we’re in a period of like regulatory slowdown. We had like a real flurry of CMS Health Tech ecosystem, CMS 0057, CMS 0062. And before that, HTI-5, we’re in the lull of like them finalizing HTI-5 and HTI-6 coming up. But the litigation is hitting a bunch of interesting points, right? Particle and Epic has been in this phase one discovery that they just sort of wrapped and now they’re butting heads saying, well, Epic’s saying, “We want to do a summary judgment. We want to close this puppy off. Market definition sucks. Let’s get out of here.” They’re trying to end that case. And Particle’s saying, “No, we proved what we had to. Let’s move to phase two, the broader discovery.” And so we should see a decision there coming up, which will be exciting. I think the judge will hear the summary judgment motion and then may choose to move forward is my guess. But Epic does have pretty good grounds if they get the trial in terms of the market definition. Antitrust is really hard to use against systems of record because systems of record rarely get to the size and market penetration of 70% or 80% that is usually indicative of traditional antitrust. And antitrust is changing a lot right now, but still.

Brendan Keeler (19:32): If you only have 41% market share, it’s a tougher case to make, especially if you’re in front of a judge with a more traditionalist view on what markets are.

Pryce (19:41): And just to be clear there,

Brad (19:41): 56.9% of hospital beds though. KLAS, yeah.

Pryce (19:45): Ooh, but not 70.

Brendan Keeler (19:46): Still low by antitrust measures. And so just antitrust as a tool is really well geared towards network-based businesses, like the train networks, right? Break up the train networks because networks tend to move towards ubiquity, move towards really strong market control. Like Surescripts, right? Surescripts had antitrust against them.

Pryce (20:07): Well, and they specifically, as a virtuous cycle, continue to succeed if they, you know, close off competitors or purchase competitors. And all of a sudden it’s a special type of differentiation. If you have the ubiquitous network instead of a network, that’s useful.

Brendan Keeler (20:25): Right, it’s not linearly tied. Every new node is exponentially more valuable in a network-based business.

Pryce (20:31): And I want to clarify too, you’re saying systems of record rarely reach that 70% threshold that maybe is arbitrary, but sort of indicates potentially a monopoly. But they get blamed for antitrust all the time because of how challenging it is to switch away from them. Is that the idea? Like how challenging it is to be a new market entrant and compete effectively? Lock in.

Brendan Keeler (20:50): Yep. Yeah, the switching costs for these type of software, it’s again, nonlinear. It’s like the bigger they are, then it’s the exponential switching costs. And so these types of software, EHRs, but also ERPs, systems of record fail what’s called the SSNIP test, right? The small but significant increase in price. And so in traditional economics applied to antitrust, if you were to change the price of a product and increase it a small significant amount, would that cause people to switch to an alternative? And to like a bottle of Pepsi? You’d switch to Coke, right? And so then that hypothetical monopolist test fails. In the case of systems of record, well, you could raise the price a little bit and you’re like, man, the cost of me moving is 10x that, it’s 100x that. And you see that in KLAS reports, not just for Epic, but for EHRs where they say, yeah, I’d move my EHR, but it’s too expensive. Like the KLAS report just came out and a bunch of people said that about Oracle. Said, I would change off of Oracle like 33% or something, but I’m not going to because it’s too much work. And so this type of software almost uniformly, even for non-market dominant EHRs and systems of record, fail this test. It’s the paradox of antitrust applied to systems of record that it can be both not hitting the metrics needed for market penetration, but also kind of universally failing the SSNIP test. All this is to say, I’m not optimistic in just a general principle towards the Particle case, towards the Texas versus Epic case, which is another antitrust case. And then CureIS, CureIS versus Epic is an antitrust case, but also an information blocking case. So it’s a little bit, got more levers to pull there potentially.

Pryce (22:38): The spinoff movie and the Epic cinematic litigative universe.

Brendan Keeler (22:41): Yeah, the collab, right? You know, the crossover event we’ve been waiting for. But we should see action on most of these, right? CureIS is having some interesting developments on their discovery. And AADJ, the American Association for Disability Justice that sued Epic for antitrust, the brief by Epic is due today. So we should have a juicy response from Epic by midnight tonight.

Pryce (23:11): Can’t wait.

Brendan Keeler (23:12): Alright, enough about litigation. What if we cut over and talk a little bit about the CMS?

Pryce (23:16): Ooh, yeah.

Brendan Keeler (23:17): What’s happened, Pryce? Do you know?

Pryce (23:19): You’re talking about the CMS Health Tech Ecosystem adding a new vertical of workflow, you know, new bodies of participants, but this is for the electronic prior authorization, which by the way, shout out, Caitlin Owens. Apparently one of my good friends from college was on stage with Dr. Oz when he made this announcement at the CMS. She works for Axios and she’s really badass. So Caitlin Owens will not listen to this, but she’s great. So they announced this past week that they’re adding electronic prior authorization to the list of use cases that the CMS HealthTech ecosystem is for. Is that right?

Brendan Keeler (23:52): Yeah, they’re creating a new pledge category.

Pryce (23:55): Pledge category. Ryan, what did you take away from this? Have you read through it?

Ryan Tucker (23:59): I have a bit. I think the main takeaway is who it’s for. The provider, payer, provider side is very much included. Clearinghouses, I think, were snubbed out of this, maybe purposely so. But I thought that was interesting because most of the transacting that happens on that level that I’m aware of and that the folks who are preparing for electronic prior authorization, lots of clearinghouses. So it seems like the government is actually trying to direct away from the usage of clearinghouses based on what they’re trying to incentivize here.

Brendan Keeler (24:30): So you can be an EHR, you can be a provider, you can be a payer, or you can be a network to pledge into this use case. Okay, maybe a clearinghouse could pledge as a network, but not in the way the health tech ecosystem is structured. If you do the pledge as a specific category, like a data network, it’s kind of all or nothing. You have to go and do facilitate patient access, you have to go and provide treatment, the treatment exchange, you have to facilitate the operations exchange from payers to providers. You have to go full bore into all of the pledge pieces. So, okay, so then if you...

Ryan Tucker (25:10): Which they’re just not positioned at all to do so.

Brendan Keeler (25:13): Yeah, yeah, right. Totally. You’re asking an administrative network to be a clinical network.

Pryce (25:19): I pulled up the press release here. We’ve got providers that are committing and then we’ve got electronic health records that are committing. So presumably that’s the submitting system of the electronic prior authorization would be the EHR instead of point solutions or clearinghouses who could help out. And then the networks are b.well, CommonWell, eHealth Exchange, Kno2. Those are CMS aligned networks. They’re already, you know, used to exchanging clinical data and sort of easier for them to tack on Da Vinci type transactions with regards to prior authorization requests. You’re saying that’s easier than like a clearinghouse (like Change) all of a sudden becoming a full on FHIR network and CDA network. Is that what you’re saying, Brendan? Like one of them is easier to transition into both administrative and clinical.

Brendan Keeler (26:08): Yeah, I mean, so prior authorization is one of those use cases that if you squint from one vantage point, you’re like, well, it’s always been in HIPAA administrative transactions. It’s an administrative transaction. It’s in the clearinghouse and payer provider data exchange lens. But then you squint from another vantage point and you’re like, wait a minute, this is a clinical transaction because inherently you need to be sending a bunch of clinical information across the wire. For a while, there were these two domains that the administrative transactions did a lot of X12 and were very payer-led workgroups like AHIP or WEDI. And then you have the HL7 and other workgroups doing the clinical stuff, CDA and the HIEs, and never in the middle shall they meet. Well, now in the middle, they’re meeting time and time again, and it’s leading to friction points as the different players want to use different standards, right? Maybe use X12 or use FHIR, as well as this. This is a manifestation of this where it’s like, okay, this is kind of gearing things to run over the clinical data rails, right? All the networks that are pledging are clinical data networks. So the ones that pledged to prior auth, b.well, CommonWell, eHealth Exchange, and Kno2? All clinical data networks.

Pryce (27:22): As a network pledging to the prior auth section, don’t you also just need to be a CMS aligned network, meaning they have to serve all of the use cases. So they’re particularly, given that they’ve been doing this for the past year, they’re particularly well positioned to say, yeah, we’ll do that one too. When in reality, like a clearinghouse might already have the infrastructure that’s prepared to serve this use case a lot better, actually.

Brendan Keeler (27:44): Yeah, and that’s the tension, right? That we’ll see play out. The thing that I like about what the CMS HealthTech ecosystem is doing is saying, “Okay, everyone’s off like building in their little corner to meet CMS 0057 or HTI-4. We’re going to convene.” And that’s been a theme of the Health Tech Ecosystem is convening and building a space for dialogue at a very rapid pace. Plus for that, but at the same time, you’re kind of squinting, you’re implicitly maybe building winners and losers or trying to orient towards the clinical data side of the house, which I don’t know if that’s right or wrong, but it certainly seems like the outcome that is being affected. And so there’s a tension there between, we only have nine months left of this bad boy until CMS 0057 is required for CMS plans, right? Medicare, Medicaid, CHIP, and ACA plans. Oh boy, it’s May, not March. I have two kids. That’s my brain is scrambled. But yeah, so seven months and the convening might be happening a little late given the balls that are in the air. Is that the right metaphor? Seven months, right?

Pryce (28:52): Yeah, yeah. Well, really, the die have been cast is what it seems like. I’m kind of like, I hope nobody is still picking their prior auth vendor for the regulation date.

Brendan Keeler (29:04): Well, we know that they are. Given the various prospects and the RFPs we’ve seen out there, there’s certainly a lot of things to be finalized in the market.

Brad (29:06): Yeah, I was gonna say.

Ryan Tucker (29:07): Definitely.

Pryce (29:12): Well...

Brad (29:17): Jumping in, this is all exciting. We’re friends with a lot of people that work at these companies and it’s good to see the collaboration. In fact, it makes any conference that much spicier and interesting, but the clipboard is still breathing. And so every new one of these to me is an increased chance of failure. In all things, a lack of constraint means you can’t focus. Every administration has a clock running against it, right? Like the day they get into the office, they know that there are, okay, Ryan, success. Let’s pretend.

Ryan Tucker (29:53): Well, we hope.

Brad (29:54): Okay. Reasonably, everybody at CMS should understand that there is a time when they will leave working for the government and they would like to show something for it. But like, are we actually changing something for patients? And I can tell you, I went to NYU just recently where I get all of my healthcare, and they have everything about me and they’re still handing me a clipboard to ask me like, is everything right? So.

Brendan Keeler (30:19): It’s been six months. They’ve been super effective.

Brad (30:22): It’s not been six months, it’s been almost a year, we’re almost at the 250th birthday party!

Brendan Keeler (30:26): They kicked off a year ago, in reality, everything got going October, November, December. That is warp speed for doing stuff in the government. And so I give a lot of credit to the Health Tech Ecosystem for advancing identity-proofing discussions, advancing patient access discussions, prototyping and putting stuff out into market, which is a necessary prerequisite for the ONC and other regulatory bodies to require things in rules. And so did it get rid of the clipboard at NYU? No, but did it prove stuff out in, if it proved stuff out in market, then they can go and require it in a rule. And that is what the whole point is, is not to get to ubiquity, it’s to prove stuff out in market such that they can go and say, “Thou shalt” via HTI-6 or another rule.

Brad (31:15): All right, I’m gonna argue with you about this, but.

Brendan Keeler (31:19): Next time we’re together with a beer, we can fisticuffs or something.

Brad (31:23): Maybe Amy Gleason is Simone Biles and she’s gonna get all-around gold. We are all hoping for it. We are all hoping for it. But like, you know, sometimes I just wanna see a gymnast that is fantastic at floor routine and we’re confident they’re gonna win a gold. That’s all I’m saying.

Brendan Keeler (31:39): Well, that is a great metaphor for us to end on today. This has been a great episode of The Information Exchange. See you guys next week.

Brad (31:41): Hahaha.

Pryce (31:47): Wild ride. Thanks all.

Brad (31:50): Tens all around.

Ryan Tucker (31:50): See ya.

The Information Exchange does not sleep¹, because, well, CMS is absolutely dialed in lately:

* Brad recaps the CMS Aligned Networks launch event in DC: CLEAR, ID.me, TEFCA rails, and Humana’s senior care demo all got stage time, but the question is what happens on the non-patient-access tracks before July

* ACCESS approved its first cohort. Brendan plays optimist on CMMI’s willingness to swing big on outcome-aligned chronic care payments while Brad plays pessimist on lemon-dropping and the 50% withhold that could empty out year two. A Polymarket line gets opened at 60%.

* CMS-0062 was supposed to be a tidy little drug rule. It is not. We walk through why it’s bigger than 0053, layers onto the 2024 prior auth rule, and in some places contradicts the claims attachments rule from three weeks ago, including the buried RFI to certify payer technology (HTI-2’s ghost returns)

* Russian doll payers, Succession-level CMS subplots: why a single payer name hides 15 claims systems, why ERISA keeps TPAs out of reach no matter how well you wire things up, and whether HIIG and the HIPAA standards group are copacetic or knife-fighting over X12 vs. FHIR

* John Deere lost its right-to-repair fight. Brad flagged it and Brendan connects it straight to the antitrust and information blocking playbook, diabetes device jailbreaking, and every system of record’s eventual discovery of platform rent extraction

* Salesforce went headless. Agentforce opens the UI, APIs, and MCP layer. Brendan argues it’s a per-token pricing play, not altruism. Brad counters with the DoorDash problem and why Epic’s moat is the hospital’s local politics, not the software. Brendan plays foil: in some fraction of the multiverse, this looks as dumb in retrospect as cable companies building streamers.

Are you curious about Brad’s Wisconsin farming roots? Wondering about the novel gambling-based business model for the podcast? Or wondering why Missingno is in your inbox? Listen to hear more.

¹ Aside from the two week breaks between episodes

Relevant Articles

* CMS Health Tech Ecosystem First Wave Event

* ACCESS Model Accepted Applicants

* CMS-0062: The Entrée Has Arrived

* CMS-0062: Same Drug, Two Standards

* CMS-0062: An Intra-Agency Cold War Goes Hot

* “Have you heard about the Pope?”

* The Great Beheading Begins

* The Infinite Rare Candies Glitch (Missingno)

* The Door Dash Problem

* How Interoperability Won on the Farm

Chapters

* CMS Aligned Networks Takes the Stage (00:00): Brad reports back from Amy Gleason’s DC showcase, where CLEAR, ID.me, and a parade of startups demoed patient identity, TEFCA-powered history pulls, and QR-code check-ins. Payers and EHRs showed up, Humana ran a senior care coordination demo, and the crew reads the tea leaves on how much of the non-patient-access agenda is actually moving ahead of July.

* ACCESS Approves Its First Cohort (03:20): CMMI’s outcome-aligned chronic care model (Advancing Chronic Care with Effective Scalable Solutions) lands its first participants. Brendan plays optimist on why ambitious failure is the point; Brad plays pessimist on lemon-dropping and the 50% withhold pushing providers out in year two. A Polymarket line on success gets opened at 60%.

* CMS-0062, Not Just a Drug Rule (09:14): The rule that was supposed to be a tidy RTPB cleanup turns out to be bigger than 0053, layering onto the 2024 prior auth rule and contradicting the claims attachments rule from three weeks prior. The gang maps the scope: Medicare Advantage, Medicaid, CHIP, parts of ACA, and why ERISA keeps employer plans out of reach no matter how well the TPAs wire things up.

* Payers as Russian Dolls (13:16): Why a single payer name can hide fifteen claims systems and five acquired Medicaid plans, why PBM and plan rails look nothing alike, and why CPT-2 codes keep haunting Brad’s career. Pryce makes the case for shifting regulatory focus from EHRs to the entities actually holding the risk and the purse strings.

* Certifying Payer Tech (16:14): : The ghost of HTI-2 returns! An RFI buried in 0062 proposes extending health IT certification to payer technology, a ZombieHTI-2 idea that would turn payer vendors into potential information blocking actors. Brad and Pryce go thumbs up; Brendan predicts a deafening “no way in hell” from payer tech comment letters.

* Step Therapy, ADT, and Succession-Level CMS Subplots (22:28): The other RFIs get a quick pass: step therapy portability as the killer payer-to-payer use case, ADT notifications getting another look, and the telling fact that 0062 tells you to use FHIR Da Vinci for prior auth while 0053 just blessed X12 for attachments. HIIG vs. the HIPAA standards group: copacetic swap or internal knife fight?

* John Deere and the Right to Repair (23:59): A Wisconsin boy’s late-night text turns into a clean antitrust parallel. Farmers buying forty-year-old tractors to escape dealer lock-in, diabetes devices getting jailbroken, and why every system of record eventually rediscovers platform rent extraction. Brendan lands it on interoperability as the throughline.

* Salesforce Goes Headless (And So Will Everyone Else) (26:38): Agentforce opens the UI, APIs, and MCP layer, and Brendan argues this isn’t altruism: per-token agent pricing beats per-seat licensing at scale, and systems of record would rather capture the agent economy than get scraped by computer-use bots. Pryce extends it to EHR nurse-bot licensure and the commoditization of the front end.

* Why the Moat Probably Holds (31:14): Brad counters with the DoorDash problem: operational embeddedness is the real moat, and Salesforce opening up mostly makes it harder for four dudes in a garage to dislodge decades of Fortune 500 data. Epic’s value extends past the software into the hospital system’s local politics, ordinances, and employer relationships.

* The Cable Companies Building Streamers Risk (33:59): Brendan plays foil: SaaS has maybe four assets (UI, data, schema, business logic), and Salesforce is giving away two to four of them with only a legal agreement standing between them and an upstart. He doesn’t have conviction, but in some fraction of the multiverse this looks as dumb in retrospect as the streaming wars.

* Kalshi Bets and Signoff (35:57): Closing odds, a final pitch for the podcast’s gambling-funded future, and the observation that the American economy is now just healthcare and gambling anyway.

Transcript

We ran the transcript through an LLM to smooth it out. So it’s a rough approximation of the conversation (and in many cases significantly clearer than our rambling), but notably diverges from the word-by-word blows quite a bit.

Brendan Keeler (00:00): Ladies and gentlemen, we are back. This episode is going to be CMS-titled, because we’re going to talk a lot about the Centers for Medicare and Medicaid Services. Brad, last week you were boots on the ground in DC. There was an event. What went down?

Brad (00:12): Yeah. We missed you all last week because CMS had a big event to celebrate the first launch of applications leveraging CMS Aligned Networks. Amy Gleason brought together a couple hundred people in DC. Much of it was to reiterate the goals of CMS Aligned Networks, introduce some potential new avenues that they could push on, and then allow vendors to show what they were doing with the new rails that CMS is trying to put in place. A ton of it was focused on patient access. That’s something Amy’s been very transparent and consistent about. So we saw CLEAR and ID.me get a lot of screen time, showing patients being able to verify their identity through those solutions and then use the TEFCA rails to pull down their patient history, along with some of the workflows that enables: patients getting faster answers for care questions from AI, checking in and providing a longitudinal patient record at the front desk using a QR code, some scheduling solutions. It really covered the map. Oura did a demo, yes. That was a particularly excellent use case or demo that they showed. One of the things that’s clear is that many of the major payers and EHRs were represented and consistently shown.

Pryce (01:22): Wearable technology, you know.

Brad (01:38): But there also are a number of startups that are finding quick paths to market access. So overall, some of the things I took away: Amy has been hard at work for the last nine months trying to get people going on these. And while there’s progress, there’s still a long way to go to get this to tie together into a cohesive strategy.

Pryce (01:52): Thank you, Amy.

Brad (02:01): CMS, just across the board, with the number of things they’re trying to do, has really pushed their technical team to be able to support things like claims data, provider networks, patients pulling all of their medical history. Nobody expects the government to be at the forefront of those things, and I think they’re showing that they can move quickly and they want to.

Brendan Keeler (02:22): One question I think is pretty prevalent in the industry, and I certainly have it: we’re seeing a lot of success via the CMS Health Tech Ecosystem for patient access and Kill the Clipboard. That’s where a lot of those demos are focused. What about the other things? You said payers were there. Did they demo? Were they showing participation, or was it more silent wait-and-watch and maybe do stuff as we get closer to the July date?

Brad (02:49): Humana had a couple of demos. There was an application for senior care coordination that’s AI-driven. And they showed scheduling through their Medicare providers. It was nice to see some providers trying to expose their networks and enable scheduling.

Brendan Keeler (03:06): CMS is kind of firing on all cylinders. They have the event, and the CMS Health Tech Ecosystem continues to rip and do things, but CMS is big and sprawling and multifaceted. Pryce, what else is going on?

Pryce (03:20): ACCESS, right? We just heard this week about the first participants who were approved to participate in the ACCESS program. And this is, as we mentioned in the last podcast, one of those brilliant backronyms. ACCESS stands for Advancing Chronic Care with Effective Scalable Solutions. That one’s good. I like that a lot. But this is one of those payment models CMS released earlier this year. And then they said, hey, if you want to participate in this new program, the payment model whereby we say, hey, we will give you payments if your organization participates in ACCESS and proves outcomes with members that are being cared for by traditional Medicare. So these are outcome-aligned payments. This isn’t like, well, we’ll give you a payment if you give Pryce an Oura ring, or we’ll give you a payment if you see Pryce for an encounter. It’s: we will give you a payment if you can prove to us that Pryce’s blood pressure was X and has fallen to Y. They’re trying to incentivize the fact that, especially with the proliferation of these tools that can automate a lot, like AI, or these tools that are literally in the hands of people, if everyone can care for themselves and reduce the burden on a provider, it might take five minutes to look over these numbers. But really, Oura or Whoop, these companies can start participating in a way where they say, I’m going to sign up as a Medicare Part B provider in some form or fashion. I don’t think Oura was even in the initial list of accepted applicants. But the point here is that the groups who have been accepted are planning to use distribution of technology to relieve the burden that is otherwise centralized on one provider to care for a thousand people who are all over 65 and trying to be cheap, in terms of healthcare costs. So that was exciting from this week, but I didn’t go much deeper. What did you all hear?

Brendan Keeler (05:11): Well, just a piece of color: a couple of weeks ago, when they released the financials, there was all this controversy of, how could it be so low? It’s so low. But that is really freaking cool. Because if it works, even if it works for one or two of these groups, then we’ve proven something. We’ve proven finally that we don’t need to take status quo pricing or slightly adjusted pricing. We can do something extremely ambitious and achieve better outcomes. People’s bar for success is, oh, it has to math out to be what it is today. And it’s like, no, no, no. CMS is saying this is an experiment, because that’s what CMMI does best: experiments. A lot of times failures, but sometimes successes. And this one in particular is very ambitious by saying we’re going to take a big old swing at this in ways we haven’t before. So I get why people are not happy that it doesn’t pattern-match prior structures they have in the employer market or with CMS and other types of programs. But that’s why we’re doing it this way. And if it doesn’t math out, you don’t want to take that risk, Godspeed, go some different direction, do what’s being done today. But if you do and you can make it work, well, you’ve just changed healthcare maybe.

Brad (06:23): We have to have an optimist on this podcast. So I’m nominating Brendan for that. There are some things about this that are really cool. We called out the usage of nationwide rails, HIEs or TEFCA, for reporting this data back. Really cool. I’m not going to make everybody sit through my story about trying to run an HbA1c testing program with one of the largest payers in the country, and they wanted CPT codes, CPT-2 codes, but they couldn’t actually ingest those codes. So they knew they were getting HbA1c tests, but not what the actual risk of their patient population is.

Brendan Keeler (06:59): I think you’re making us sit through the story.

Brad (07:02): No, well, it’s much longer. It’s much longer. We are going to get some data about these patients, but I think there are difficulties with CMS trying to be the one to drive innovation models, in part because of who the patient population is. I’ve tried to get my parents to use Apple Watches, and they know how to put it on the wrist, but they’re not setting up any health monitoring.

Brad (07:24): There are incentives to enroll specific types of patients, which is probably a really small percentage of the patient population. And if you enroll a patient into the program and your cohort is non-compliant, or you’re not seeing the outcomes, 50% of your payments are being held till the end of the year. And there’s a very strong incentive for those providers to just pull out of the program. It’s probably not going to be one of these extremes, but I think we could see year two of ACCESS being barren and not having a whole lot of people who want to participate in it because there’s too much uncertainty about the payments. And then the question is, did we actually get enough data to say this is an effective type of program for us to run? Or do we find that digital health providers are really good at lemon-dropping? They’re very good at selecting the patients who know how to use technology, who are going to be very compliant. And we see reductions in HbA1c and depression and anxiety and MSK pain scores, which make the model seem way more effective than if it were rolled out to a larger population. Which is not to say we shouldn’t be doing these things. CMS has taken a lot of bets right now, and I want to see ACCESS succeed. I am more on the pessimistic side here than Brendan is.

Pryce (08:43): Who wouldn’t?

Brendan Keeler (08:46): Well, we’re turning on the Brendan-Keeler-patented probability market, or whatever it’s called.

Pryce (08:54): Polymarket.

Brendan Keeler (08:46): We’re going to Polymarket this b***h and do it at like 60% to start. So if you want in, let us know, because that’s what we’re, that’s what we’re monetizing and paying for ACCESS with, actually.

Brad (09:05): That’s how we’re funding the podcast.

Pryce (09:06): That’s great. Yeah. It’s going to, we’re going to reduce everyone’s hypertension, increase gambling addiction. That’s the goal.

Brendan Keeler (09:14): We’re not going to go down that rabbit hole because I have a lot to say about bringing back one of the oldest sins of mankind.

Brad (09:22): Speaking of sins, have you heard about the Pope? Sorry, go ahead. Go ahead, Pryce.

Pryce (09:16): Hahaha. Okay. Well, speaking of CMS being so busy, speaking of CMS being so busy, Brendan wrote a slew of amazing articles, I thought, regarding 0062. CMS 0062 is the newest proposed rule from CMS. Tell us a little bit about that, Brendan. I particularly love that multiple people have called out that it sort of came out under the guise of real-time prescription benefits, but it has way more than that in it. So what’s on the menu?

Brendan Keeler (09:53): Yeah, it’s fun because we just had a CMS rule three weeks ago, 0053, the claims attachments. So it’s like, oh, they must be good for a minute. But no, no, 0062. It’s been waiting in the wings for almost a year. It’s been chilling with OMB since the spring 2025 unified agenda, OMB being part of the agency that reviews rules to make sure they’re compliant and they stitch together and no one’s going to sue them. It sat around for a year, which is a long time, but the Trump admin had a deregulatory order that meant no new regulation, which this is. But they got through now. And in the interim, the person really pushing it from the CMS side, Alex Mugge, went to work for Oracle. So this rule, you’re kind of squinting at it. It was coming, the last remaining bit, it seemed like, from 9115, the CMS patient access rule, which added the ability to pull claims data from payers. This is the first rule that regulated payers to say, hey, add interoperability, sort of clinical interoperability. And then we had 0057, the prior auth rule, which in 2024 said, okay, now we’re going to do payer-payer data exchange, we’re going to do payer-to-provider data exchange, we’re going to do prior authorization for medical procedures. It’s all FHIR-based. And so then the last remaining thing is, well, what are we going to do about drugs? What are we going to do about medications? And so this rule on paper was just going to be a little tiny rule to say, here’s what we’re doing about drugs. But no, no, no, no, no. This is a big one. This is bigger than 0053. It compounds and expands and really takes some big cuts layering on top of the prior auth rule of 2024, and in some ways contradicts the rule we saw only three weeks ago.

Pryce (11:38): Quick reminder: all of these rules, because they’re written by CMS, really just apply to payers who are taking on risk from CMS, AKA Medicare Advantage. And they would apply to providers who want full reimbursement or MIPS incentives and things like that from CMS. So we’re still talking about a massive market-shifting trend, but affecting 40% of payments or encounters or however you want to split it down the middle. Is that right?

Brendan Keeler (12:04): More specifically, I mean, only small parts of this really even touch providers. The ADT notifications of 9115 touch providers. Most of it, almost all of it, is CMS plans. Medicare, Medicaid, CHIP, ACA, but only parts of ACA, because if it’s state-run or state-based exchanges, the same regulatory hooks aren’t in there. So that ends up being 48, 49% of insured Americans, but certainly not all the employer-based plans, certainly not even all the federal plans. FEHB is not regulated by this because CMS doesn’t have authority. You’re like, wow, we’re going to have electronic prior authorization everywhere. And it’s like, well, will we? Maybe not. But it’s really, really hard to regulate employer-based plans in any capacity because of ERISA kind of making them immune in many ways to regulation, or requiring what’s called Tri-Agency coordination between the Department of Labor and CMS and others.

Brad (13:00): The hope here is that if they have to make this change for a TPA who can do this for the federal government, they can also expose it to their employers. Fingers crossed.

Pryce (13:10): Okay, I’m checking off TPA and tri-agency something on my bingo card.

Brendan Keeler (13:16): I mean, you would assume that’d be the case, but if you actually think about payers, they’re like the Russian dolls. What are those called? You pull them back and there’s just another layer and another layer, and they have 15 different systems. They acquired their employer plans they acquired five years ago and have totally different systems than their Medicaid plans, which have totally different systems. So you wire it up for just the CMS plans, and you’re not technically set up to communicate and do those things with the systems they might use for employer-based.

Brad (13:44): Yeah, remember when I was talking about CPT-2 codes earlier? Yeah.

Brendan Keeler (13:48): Full circle.

Pryce (13:50): Galaxy brain.

Brendan Keeler (13:51): Pryce, when you were reading it, did any of the articles or topics stick out to you?

Pryce (13:56): Gosh, a lot of it did. I was basically Slacking you the entire time because I was so excited by it. Just from a broad-strokes perspective, you were just saying a lot of this doesn’t really affect providers. For the majority of my health IT career, it’s like, we regulate EHRs, we regulate EHRs, open up EHRs. And still today, people love to be mad about or excited about what any EHR can or cannot execute on as it pertains to interoperability and what’s regulated. But I love to see this turn and focus towards payers for a lot of different reasons. From my perspective, payers have much, much less detailed clinical information about patients, about their members, than the actual acute care facility that I spent 10 days in. Hopkins EHR is going to have a lot more provider notes, vitals. They’re going to have all my lab results, who was the nurse working when I was in the middle of the night or something like that. But payers are the one ultimately carrying the risk for each of these patients, or members as they would call them. And therefore have this nice, especially if they just received claims, they have this nice sort of linear story to tell about, at least for anything that needed to be reimbursed by insurance, what service was provided, for what reason, what diagnosis. And that information starts to piece together the bones of a very clear clinical story that my psychiatrist and my endocrinologist and my PCP each only have a third of. And then you layer on the fact that, since they are holding the purse strings and they are the one who decides when and why you would be allowed to get an MRI through utilization management and prior authorization. I do like to see that CMS is acknowledging that these folks need to be as involved in patient care and turning the inflection point of healthcare costs in the other direction. Because they see it all. Even if they’re not getting detailed information, they’re trying to. They’re getting more and more through these evolving utilities that we have coming into place, like the prior authorization rule and Da Vinci exchanges, or eventually TEFCA will support Operations use. Maybe you’re not an optimist on that one, Brendan, but I thought it was sweet to see them.

Brendan Keeler (16:07): We’ll figure it out somehow. We’ll figure it out somehow.

Pryce (16:10): Yeah, turning the focus to payers was exciting for me.

Brendan Keeler (16:14): One of the RFIs in there was to certify payer technology. And that was a big deal because that was proposed last administration in HTI-2. Then we said no, no, no, all the ideas in HTI-2, that is verboten. Like that is gone. We’re wiping away most of it. And then we see a lot of them sneaking back up into HTI-5, probably more in HTI-6, in terms of FHIR Subscriptions, which were proposed in HTI-2. And here we see the proposal to expand the certification criteria to potentially hit other types of entities beyond certified health IT / EHR type tech for providers, to payers. There’s a lot of implications, but yeah, are you for or against? Thumbs up or thumbs down?

Brad (16:56): I know we talked about payers being Russian nesting dolls. This administration is focused, and I guess last administration was focused, a lot on drug pricing. The payers own PBMs. Maybe the answer to this is they acquired them. It’s a completely different tech stack. One of the things that stuck out to me, because I really haven’t spent much time on the payer side at all, is the different exchange methods between the plans and the PBMs with providers. One of the places that honestly I got stuck reading the pieces is understanding why there are such different communication rails between PBM, payer, and provider. And I don’t know if either of you can speak to that for other people who sort of got lost in the sauce reading Health API Guy.

Brendan Keeler (17:39): They’re different because they’re different entities. They just do different things and interact with different types of, like, interact with pharmacies instead of with providers. And so as you have different business types, different software emerges to support them. Just because organizations are vertically integrated and just purchased, conglomerate style, all these other types, doesn’t mean that suddenly their software is homogenous. Quite the opposite. As they become very conglomerate-y — conglomerate-y is not really an adjective, but we’re going to make it one — then they hit the limits of what commercial off-the-shelf software can provide. And they need to glue together disparate software, which doesn’t always go well, which is quite difficult. And so you see integration platforms as a service. You see Redox is in the provider space. You see Flume Health, I think, is in the payer space to stitch things together. Rhapsody. And that’s just when you’ve hit the boundaries of there being enough of the type of entity that you are, with all the business needs, where you could have one piece of software. And we’re lucky or not lucky, depending on your view, that on the provider side, the systems of record have developed to encompass a ton of the functionality that business type needs. But that’s not the case in every industry.

Brad (18:50): And so do you expect that Da Vinci, NCPDP, those standards will continue to exist in a health IT-regulated, like the payer world falls under regulated health IT?

Brendan Keeler (19:03): That would be to cement it in, and also turn the makers of payer technology into potential information blockers. They could be actors under the information blocking statute. And so I think we’re going to see a ton of payers who make tech, and payer technology vendors, comment on this rule and say, no way in hell, do not do that. We’ll do anything else. You want us to submit to CMS directly, we’ll do it.

Brad (19:24): Okay, now I know my answer. I’ll let Pryce answer first.

Pryce (19:28): Do I want them to have to do it? Yeah, I guess so. I mean, I’m not like a big fan of creating more regulation, but I am a big fan of playing whack-a-mole with whoever’s dominating the market or driving up costs. If we’re going to force the provider side of this equation to be so compliant and own so much of the costs of care, like total cost of care, and own so much of the burden, the administrative burden of utilization management, then yeah, I would love to see the other systems that are deciding when and why, and they seem like a total black box. I could go on for 20 minutes right now about Cigna and how they never reimbursed me appropriately, well, my wife appropriately, for her perfectly healthy home birth. So yeah, I’m big, shaking my fist like, you’re going to play ball the way that the rest of us want you to. Just because you have the most money right now doesn’t mean that you get to call the shots on what technology gets used and how. And to Brendan’s point, I mean, it would be a huge regulatory burden on them because their systems are so fragmented. One payer could really be 25 Medicaid plans that had been bought over the last 10 years and shoved under one name. And they all have 15 different claims adjudication systems. But damn it, I want people working together. And I don’t really care. I don’t really give a damn about capitalism when it comes to that. So sorry, Kat McDavitt and whoever.

Brendan Keeler (20:54): What about you, Brad?

Brad (20:57): Hey, listen, if it puts them under information blocking, then Cigna, Epic, John Deere, they’re all in the crosshairs. I’m for it, yeah. So many of the entrenched players did not capture market share purely through ingenuity. So much of it was driven by regulatory capture already. This feels like it is evening the playing field and introducing players who can drive down costs. Let’s go back to ACCESS. It’s been impossible for Oura or Whoop to find a way in. If they truly think that they can reduce chronic care costs, great, let’s give them a path in. So now I guess I’m pro-ACCESS.

Pryce (21:45): Let me flip this back to you, Brendan. Take out your crystal ball. There’s no chance we’re going to start certifying payer technology as a result of this proposed rule, right? What do you think?

Brendan Keeler (21:57): Correct. This is just an RFI. So in the rule, there are requests for information to inform future rules. That was one interesting one. There was one about step therapy. So step therapy being whether that could transfer between payers if you’re on these regimens, and you don’t have to go restart and change things over. And so that would be a killer use case for the payer-payer data exchange, if that’s able to be enabled through there.

Pryce (22:25): You’re like, that would be a killer use case if we could even get it off the ground in a meaningful way at all. Keep going.

Brendan Keeler (22:28): That’s right. That’s right. And then ADT notifications, I think they’re revisiting what they’ve done before and saying, is this good enough in terms of where we need to be with a nationwide capability for ADT notifications? So yeah, we had the rule itself that’s proposed. It says use NCPDP here, get rid of X12, use FHIR Da Vinci, which contradicts in some ways the 0053 rule from only a couple of weeks ago. And that’s because this rule comes from different parts of CMS. So much like payers are Russian dolls with many parts, so is CMS. CMS has different groups with different mandates, different authority, and different prerogatives. And so Amy Gleason’s group, the CMS Health Tech Ecosystem, is very different from the group that owns the HIPAA Administrative Standards, which released the 0053 rule a couple of weeks ago that chose to go and promote X12 as a standard there.

Brendan Keeler (23:21): And here we see HIIG and this interoperability group that started under Seema Verma and the first Trump admin and grew into this mandate of promoting interoperability for payers. They’re very pro-FHIR, as we can see. And they’re saying actually not just let’s go do more FHIR. They’re actually saying, let’s take something that’s X12 prior authorization, let’s make it full FHIR. You can create Succession-level subplots of what’s going on in CMS, or it could just be, you know, they’re copacetic and they just agreed to do a little swap there. Who knows?

Pryce (23:51): Who knows, we’ll have to get the dirty deets from someone. Reach out to us if you were listening to any of those crazy conversations about X12 and FHIR. Go ahead.

Brendan Keeler (23:59): Brad, you mentioned randomly John Deere. What was that all about?

Brad (24:03): Well, I have to have some random things to text you about late at night. And I come from the great land of farming, Wisconsin. A John Deere article about the right to repair came across a feed of mine Sunday, maybe? And I had been seeing stories about John Deere forcing farmers to use their dealerships for any sort of maintenance. I wouldn’t say I’ve been tightly following it, but huge decision basically forcing John Deere to open up their drivers. I don’t know that they have to open source anything, but they have to allow third parties to do repairs on the machinery, which is probably a huge hit to their business, but a boon for people who have bought this machinery and then just been screwed when it broke down in the middle of the field. I felt like it was a very natural corollary to information blocking in our industry, and also used car dealerships. But yeah, threw it over the fence to see whether or not it said anything to you.

Brendan Keeler (25:03): I mean, right. I was rock-solid. I have an antitrust and information blocking presentation that I give, and in there, well, there’s this parallel to this right-to-repair movement that is out there. So you nailed it.

Brad (25:17): Have I seen this? .

Brendan Keeler (25:30): No, I don’t think you’ve seen it, it is crazy. I went back and looked, but totally, it is the ability to share diagnostics from the software of John Deere with independent repair men and women. It was not enabled. You had to go get the certified John Deere technician. And so that sort of lock-in occurs in software of all varieties. You have it with diabetes devices that people have to jailbreak to even just fix it themselves or understand their data. And you certainly have it in software of all kinds, of all verticals, for all systems of record, where they lock it in to try and maintain a platform advantage. And they sometimes do it for good reasons, security or privacy, but oftentimes for self-serving reasons. So tremendous win in terms of antitrust and against John Deere, enforcing openness for our farmers as they have many other burdens on them at this time. And just a great win for interoperability, that we hope to see replicated, that we hope to see open ecosystems promoted to allow for co-opetition, cheaper prices for consumers and users of different devices. Yeah, send more over my desk of that variety.

Brad (26:25): Bye! Did you actually find the reporting? Would this apply to other manufacturers like Caterpillar, or was John Deere just so egregious in their behavior that they got singled out?

Brendan Keeler (26:38): John Deere was so egregious in their behavior that people were going off-market to go buy 40-year-old tractors so that they didn’t have the lock-in. Let’s go broader. We just saw another ecosystem changing dramatically. Did any of you read today’s article about Salesforce?

Pryce (26:46): Mmm, you got to get that jailbroken tractor, you know.

Brad (26:50): Remote market distortion.

Pryce (27:05): I saw enough to know what’s going on. When Brendan starts talking about headless software, he’s getting excited. Doesn’t matter what industry it’s in.

Brad (27:13): We’re making a little stretch here, but now that anybody can have access to John Deere diagnostics, is the John Deere tractor not going headless?

Brendan Keeler (27:21): HeadlessTractors.com. So we did see Salesforce make this announcement about their Agentforce platform, where they said, you don’t have to use our UI. We’re now going to, we realized we have to open up. We have to be really open and headless with our CRM. And you can connect at the UI layer and integrate whatever custom components and visuals you want. You can integrate your agents to have them running over our software via RPA or APIs or MCP, you name it, we did it all. At first blush, you’re like, whoa, sweet. That is awesome. But let’s make no mistake. Marc Benioff likes making money just as much as anyone else. So he’s not benevolent. He’s got to keep that tower going. So it’s not benevolent altruism. It is because systems of record see the writing on the wall and see that...

Pryce (28:00): Probably more.

Brendan Keeler (28:12): ...I can charge you a per-seat license and make X per seat, or I can charge you a per-token, per-action agent pricing. And then if I make your business successful, that line is exponentially higher over time than the per-seat licensing. So the shift is to make more money. The shift is to enable these businesses to be successful for sure, but to capture the value that’s coming from agents manipulating systems of record. Because if they don’t provide that tooling, which Salesforce now has, then people are just going to run roughshod over it with computer use and computer vision. And guys, we see it all the time in terms of browser-based EHRs already getting scraped up the wazoo. So I have to think EHRs and other systems of record are going to follow suit. They’re going to build these ecosystems to do the same thing.

Pryce (28:54): Mm-hmm. Or at least in their policies and procedures, they have to say, robotic process automation or agentic AI is permissive only if you have special user accounts that are for these robots, which maintain certain security points and maybe get charged a different licensure level. Because to Brendan’s point, it’s one thing to say every nurse license costs this much. Well, what if you have a nurse that does 10 times as much work, 24/7, because really it’s just Claude in the background or something? Well, you got to change the pricing model a little bit. And that’s okay. I still want to see these groups adapt to realize so much of my value has traditionally been tied up in how the user interacts with sort of the backend that they don’t see. And now it’s like, everyone needs to realize the front end is becoming commoditized. I am starting to be in my car all the time and thinking, I don’t want Google to search things. My son’s asking me how to do the glitch in Pokemon Blue so he can duplicate his rare candies. And I just want to be like, hey Claude, how do you do this? I don’t even want to interact with software, really. I want to think that I’m just saying a question out loud and getting an answer in response. And that’s what people are going to continually want from their Salesforce, from their EHR, from their tractors. They don’t want to have to go to the brand-new platinum John Deere dealership to get a diagnosis that says your spark plug’s out. They’re like, let me do it. All of these different industries sort of dance to the same beat here of, we’re going to have to change the way that we imagine humans and software interacting. And there will be fewer pinch points. Like, you have to go to Humana to ask permission for this MRI, or you have to go to John Deere to figure out what’s wrong, or you have to open up your phone to ask a question. There’s going to be fewer of those. And the more the data is opened up, the more that databases are opened up, the easier they are to interact with. I mean, everything has to change from a commercial perspective to support that.

Brad (31:14): There’s just a lot of businesses where the way that they were able to price isn’t necessarily driving value. Nilay Patel from The Verge talks about the DoorDash problem all the time. Parts of the business of getting delivery drivers or drivers on the road to do these tasks is incredibly complicated. Uber and Lyft have to incentivize people. Sometimes they take a loss on the trip just so that they know they have enough drivers on the road. The task of what food is available down the street at every single restaurant is a fairly solved problem. And if DoorDash’s value of charging a management fee is that they created that database, well, LLMs can just use it for now, but it’s a fairly easy service to replicate. Whereas you have something like the systems of record, I think are in a very strong place. Like the restaurant industry: Toast or Square are in operations of that business. They’re doing something. They’re helping that business be more effective. I think for tools like Salesforce or EHRs, the reason to open up is if they are embedded enough in driving the P&L of that business, they’re not going anywhere. And there are probably more ways for them to make money. They’ll have a ton of seats, they’ll have a bunch of agents. Salesforce moving on this is only going to make it harder for upstarts in the industry who are saying, we’re an agent for CRM, to break through. We can obviously watch their earnings and they’ll probably go up. But more than anything, a lot of these major players opening up, they are just making it harder for anybody to come in and introduce a competing piece of software, and helping their customers who are already entrenched in whatever industry they are stay there. Which is, I’m not saying that’s bad. This cycle, it may look like Salesforce is in trouble or Epic might be in trouble, but the reality is the ecosystem in which they play, the way that the hospital system knows their local population, they know their local politicians, they know the ordinances, they’re participating with employers in that area, that is value that extends beyond the use of Epic. But they have designed Epic to help them more deeply integrate with those systems. So I don’t know what my...

Pryce (33:29): Hmm. You’re saying that the skeleton of all these systems is already customized. Like, who cares what it looks like? Put makeup on it. Yeah. Yeah.

Brad (33:37): Yeah, and right, it’s great for them in the short term. I don’t know, Salesforce sells 20% less seats, but the reality is, there’s not some CRM that four dudes in their garage are building today that suddenly all of the Fortune 500 companies are going to decide, let me dump decades and decades of data.

Brendan Keeler (33:59): I do want to just play foil, and where that’s optimism, maybe be pessimism here. How does this become like all the cable companies running to build a streamer during the pandemic? It could be something like that, where now in retrospect, how dumb were you? You just gave away your business model. Well, if you are allowing it and becoming open, and your data schema is open, and you are giving away the user interface layer, then at a certain point, it is trivial to vibe-code a replacement for software. When you intrinsically understand workflows and data concepts.

Brad (34:31): Well, that’s the part that’s different. What is the workflow for me consuming content? I pick up my remote and I click around. The barrier to entry in B2B software is just so much higher than building a streamer. They bought a shitload of content and they made it really easy to access.

Brendan Keeler (34:49): I just meant less that it will be exactly like that, and more that if this action of all these systems of record saying, yeah, we’re going to monetize by opening up and giving away the layer, it could look as dumb as them all moving and creating a streamer rather than using the bundle on cable. I think that reality is because there are only three assets to SaaS. There’s the user interface IP. There’s the data and database layer IP (I guess four assets, that’s everything), the data layer as data and also the structure. And then the middle layer being workflow, the business logic. And the more you give up of them, the less you actually have that is unique to you. And right now I’m hearing Salesforce giving away two or three or four of those layers that give a lot, it’s a lot of trust that only a legal agreement is in between an upstart and their disruption. So that’s just something to think about. I don’t know if I believe it. I don’t have conviction there. I actually think everything you said is probably how I view the world and what I’ve written before. But some fraction of what might be possible here in the multiverse is disruption.

Brad (35:57): So what are our Kalshi bets for this part?

Brendan Keeler (35:59): Yeah! 5%, 5%!

Pryce (36:02): You know, they’re opening all of this up and they’ve got an MCP layer and the API layer. But each of those, they’re not opening up the database layer. They’re opening up some abstraction of the business logic’s interaction with the database layer. So you don’t really necessarily know which columns you’re writing to and when and how, and what the CRUD logic and things like that is. If you’re using an MCP call, it’s just kind of like, and then on the backend, yeah, on the front end, I kind of got to talk to an LLM and said, or an agent did this. But then on the backend, these companies are purposefully abstracting plenty of their secret sauce for...

Brendan Keeler (36:40): Ultimately, is openness building dependency with your surrounding ecosystem? Or is it allowing one of them to slide the knife in easier? We shall see. But there’s an argument to be made either way.

Pryce (36:52): Yeah. Let’s bet on it.

Brendan Keeler (36:54): Okay. What should the name of our betting site be, since the American economy is only healthcare and gambling now. Anyway, on that very positive note, I think we’ve gotta wrap. Everyone have a great week or weekend, whenever you’re listening to this. See ya.

We're back after a few weeks off, and we came in hot:

* OpenEvidence landed its first B2B deal at Mount Sinai! So we talk about what happens when a PLG darling tries to grow enterprise muscles, the competitive landscape as they do so, and whether the real moat is product or sales.

* Then we pivot to MEDVi and the New York Times piece that has everyone talking: can you really vibe code a billion-dollar telehealth business for $20K? (And should you?)

* We wrap with some wonkery — the ONC is the ONC again, the O-PIMP is born, and I walk us through why the Henry Schein v. Vyne case might redraw the line on what counts as a health information network in America.

And yeah, you’ll have to listen to understand why this exists (and why it goes so hard):

Relevant Articles

* OpenEvidence Announcements

* Mount Sinai to integrate OpenEvidence AI enterprise-wide

* OpenEvidence and Tandem Partner to Streamline Evidence-Based Prescribing and Prior Authorizations

* OpenEvidence launches Coding Intelligence

* Abridge and clinical decision support

* OpenEvidence’s Gambits: Some analysis of where OpenEvidence might go after PLG from last summer, including the enterprise motion

* From Alert Fatigue to Approval Fatigue: An oldie showing how it was always logical ambient scribes would infuse CDS, another attempt beyond the pop-up

* When Horizontal Meets Healthcare: A piece about OpenAI and how their healthcare business model differs and threatens different players

* One Copilot to Rule Them All: The copilot convergence, which OpenEvidence is now rapidly joining

* Abundance and Agent: A discussion of how AI-powered software development’s marginal costs mean players sprinting to build it all

* The PLG Trap: The OpenEvidence v Doximity cases shows how the sword of openness (PLG) cuts both ways, as we discussed on the show

* How A.I. Helped One Man (and His Brother) Build a $1.8 Billion Company: The NY Times article on MEDVi

* Healthcare at Internet Scale: An article from last summer about the OpenLoop lawsuit that mentions MEDVi

* Rik Renard’s MEDVi post

* Death to ASTP, Long Live ONC

* The Battle for the Soul of HIE (or at Least the Definition)

Chapters

* OpenEvidence’s Enterprise Pivot (00:00) - OpenEvidence lands its first B2B sale with an enterprise-wide deployment at Mount Sinai, embedded directly into Epic. The crew unpacks the tension between product-led growth and enterprise sales in healthcare (BAAs, PHI access, institutional sign-off) and how this move finally brings OpenEvidence into UpToDate/Wolters Kluwer’s competitive set for real.

* The Great Convergence: Scribes, CDS, and RCM Collide (04:28) - Abridge partnering with Availity and UpToDate, back-office co-pilots moving upstream, front-office co-pilots moving downstream. Brad flags clinical trials enrollment as the next obvious adjacency, and the group debates who wins the “wedge into the chart” race.

* PLG in Healthcare and the BAA Problem (08:21) - Why product-led growth has historically been almost impossible in healthcare because of PHI and HIPAA. OpenEvidence may be the closest thing to a Figma for healthcare, but the harder, more valuable use cases require enterprise contracts — and that’s a different muscle entirely.

* Vibe Coding the Roadmap: OpenEvidence’s Shipping Velocity (13:03) - OpenEvidence is announcing something major every month. The group attributes this to LLM-assisted development and frames it as a wake-up call: if you’re not adopting Claude Code or Codex-type tools, you’re behind. But speed cuts both ways — if anyone can build an LLM wrapper on the same corpus, is velocity a moat or a vulnerability?

* MEDVi, OpenLoop, and the GLP-1 Gold Rush (18:40) - A deep dive into MEDVi, a telehealth front-end on OpenLoop’s white-label MSO infrastructure reportedly generating $1.8B in revenue. Brendan connects it to an older lawsuit alleging fraudulent oral tirzepatide marketing. The real question: when website creation, content generation, and national distribution all approach zero marginal cost, harm scales faster than regulation can respond.

* AI Doctors and the Guardrail Question (25:51) - If the provider layer also becomes marginal cost — AI doctors on top of white-label infrastructure — the need for guardrails becomes existential. The group draws parallels to Cerebral, opioids, and the recurring pattern of technology outpacing oversight.

* ONC Is Back: ASTP Reverts to Its Original Name (28:25) - The ASTP is reverting to the Office of the National Coordinator. The mission doesn’t change, and the pattern is familiar — Democrats expand, Republicans slim down. Pryce mourns the logo, reveals the internal Office of Policy is now the Office of Programs and Implementation (”the O Pimp”), and the group riffs on missed merch opportunities.

* What Is an HIE/HIN? Vyne Dental v. Henry Schein One (34:50) - The episode’s deepest policy cut. Henry Schein withdrew from ONC certification, arguably to dodge information blocking. Vyne is trying to use the HIE/HIN actor definition instead — but that definition is famously ambiguous. Brendan breaks down the three exchange topologies and how the ONC preamble’s carve-outs could let nearly every network argue it’s not an HIE/HIN. A Maryland judge’s ruling in 2–3 weeks could reshape actor status for every clearinghouse, ADT network, and API platform in the country.

Transcript

We ran the transcript through an LLM to smooth it out. So it’s a rough approximation of the conversation (and in many cases significantly clearer than our rambling), but notably diverges from the word-by-word blows quite a bit.

Brendan Keeler (00:00) Ladies and gentlemen, we are back. It’s been a bit, a few weeks. We got Pryce, we got Brad, we got Brendan. And we’re here to talk about — let’s start with some of the buzzy stuff. OpenEvidence making moves. Pryce, what are you hearing?

Pryce (00:02) We back.

Yeah, so diving right in, some of the news coming out of this week was that OpenEvidence has seemingly made its first B2B sale or engagement with Mount Sinai in New York. Apparently they’ll be embedding their application directly into the EHR, which is interesting.

Makes sense from a workflow perspective, but interesting for a lot of the things that we’ll talk about shortly and how that allows these products to sort of work in and around each other or compete with each other. And that EHR at Sinai is Epic, if that’s not self-explanatory to anyone. So yeah, OpenEvidence to me is sort of the evolution of UpToDate and the idea that clinicians leverage it to see recent studies, verified research, get help in coming up with a care plan for the patients that they’re treating. And now they’re gonna have this AI tool, which Healthcare IT News is reporting as Mount Sinai’s first enterprise-wide AI deployment across clinical roles.

Which was surprising to me considering I think they’re live with Microsoft’s dictation tool. But yeah, first B2B sale for OpenEvidence. It’s interesting, it’s cool. It also means a lot about where the market is headed, where they’re headed, what other companies who might not have had OpenEvidence on their radar will need to do in order to continually compete for physicians’ attention. And for value.

Brendan Keeler (01:41) Yeah.

Pryce (01:42) What do you all think about that?

Brendan Keeler (01:43) What’s interesting is you said they’re competitive with UpToDate. They were doing a similar job to be done — they were providing clinical evidence, they were providing studies — but their go-to-market motion to date until this was totally different, right? They were ad-supported PLG. And so this is a new muscle that actually finally brings them into the competitive set.

Pryce (02:06) PLG being product-led growth for those who aren’t like Brendan and Brad, always plugged into the…

Brendan Keeler (02:14) You don’t love acronyms? We’re not going to just toss acronyms left and right? CDA, HL7…

Pryce (02:18) I mean, well, those I do love because I understand them well. Yeah, so you’re saying OpenEvidence sort of went to market as like, hey, if you’re a physician, you should download this app. It’s free and useful to you, but I’ll make money off of ads. Whereas UpToDate was always — was that Wolters Kluwer? And it was a B2B sale? Is that right?

Brendan Keeler (02:42) Yeah, you’re charging a couple hundred bucks a seat, enterprise contracts with a totally different motion that’s just hard, right? Like if you’re used to just saying, hey, pick this up, make it really frictionless for Dr. Smith — or actually you or me, like it’s actually not that hard, as proven by the Doximity lawsuit, for anyone to sign up for OpenEvidence and use it. You can just sign up.

You do that and you’re building a very different muscle. What are ads? How do we do ads safely? How do we go to pharma and monetize via pharma? That’s what they’ve historically done. It’s always been a question of, okay, when they get popular enough, how will they lever over into enterprise markets to sell? Do they have the muscle to go to the CIO, CISO, chief medical officer and say, hey, you should rip out UpToDate and put us in? That’s been the question — do they have that sales motion?

Brad Thorson (03:31) Yeah. It’s a really nice natural experiment of what is the right sales entry point for these AI-enabled enterprise products, because every time somebody gets a strong enough foothold with a large enough client, they are looking for — okay, yeah, I’m doing your ambient note taking, but now I need to look at, can I do ICD-10 and CPT code generation?

It does feel like in the chart, OpenEvidence is competing against Wolters Kluwer / UpToDate, but they’re also competing against the scribes and they’re also competing against HCC coding applications.

Do we have evidence of the RCM tools moving up into the chart? And then we have patient engagement and whether or not that’s going to continue to follow the patient into the visit. It’s really a question of who can sell and what partnerships look like.

Brendan Keeler (04:28) Right. And this is the great convergence that’s been happening, right? You have Abridge partnering with Availity for prior auth and partnering with UpToDate for clinical decision support.

So the convergence of all the jobs to be done for the provider — not just note taking. Abridge has expanded to be a full clinical co-pilot, but they’ve always been B2B. And then, like you’re saying, the back office co-pilots are moving upstream, the front office co-pilots are moving downstream, and now you have this heavy weight of the product-led growth market saying, actually, I’m gonna try and lever over and compete in the enterprise market. That’s gonna be challenging.

Because they are well funded if nothing else, and they are aggressive if nothing else, and they launched multiple things. They launched prior authorization in partnership with this.

Brad Thorson (05:12) I was just going to say, some tools may not even have an enterprise sales motion directly into systems of record or the care delivery organizations. Tandem is just going to go in with OpenEvidence.

Brendan Keeler (05:27) Yeah, yeah. And I think the two things that come to mind for me — I don’t know if you guys have an opinion — but we think a lot about integration. I’m curious what their integration looks like with Epic and EHRs and if they need help with that. I mean, who could help them with that? And two, ads. They can’t possibly go sell to Mount Sinai and then be surfacing ads. Can they? But I don’t really see…

Pryce (05:40) I don’t know who would help with that.

Brendan Keeler (05:55) You would assume not, but…

Pryce (05:57) It’d be sweet to be like in Epic and then if you click a button you can buy tickets to the next game that night, because I would. OpenEvidence is getting paid.

Brendan Keeler (06:05) Yeah.

Brad Thorson (06:05) Wait, they don’t even have to serve ads. I mean, who knows what the contract says, but all they need to know is that these podiatrists are commonly following this care path and ending up at a certain decision. That data enriches the free product that they have. And ultimately, pharma is looking for better attribution. Okay, I sent my reps into Sinai, and they’re telling me that I have to pay their expense bill of $20,000. How come my providers aren’t ending up on a care pathway that recommends my drug? I’m not saying that’s the motivation, but that’s a very easy product to build. And there’s going to be a lot of pressure from the people who are putting up the money for OpenEvidence ads to get better attribution.

Pryce (06:51) Yeah.

Okay, so I have two quick thoughts. One is just the product-led growth concept where OpenEvidence started by convincing — gosh, I feel like it was some absurd number — 30% of physicians in the country are leveraging it.

Brad Thorson (07:11) Insane success. Would have never, ever, ever predicted it.

Pryce (07:14) I think a lot about tools that want access to clinical data and how if they were patient-facing tools, then the patient would just need to authorize their access to clinical data. But guess what? No way in hell can you convince a million, 10 million, 50 million patients to download something.

So the wedge of being like, well, my end user is the provider. And then once you have a couple of million providers using your software, then it’s like, go tell your organization to just put this in your EHR. And then to Brad’s point, you’ve got a business associate agreement set. Somehow maybe Epic and Oracle and MEDITECH maintain the rails of the clinical documentation or the RCM work because that’s what EHRs are so sticky for — really that enterprise business that they’re driving. But does the brain of the EHR and the insight of “If this care pathway, then this” and selling data to pharma or clinical trials start becoming a little bit more of a battleground?

Brendan Keeler (08:21) What I would say is one tension here — when you are just doing clinical decision support, PLG, like PLG in healthcare is almost impossible because of PHI and HIPAA. You have this tension of needing a business associate agreement. So if I go to Dr. Smith, who’s part of Mount Sinai, and say use my tool — it’s just clinical decision support. Well, great, fine. I can pick it up and use it. And Doximity previously had success with that for just doctor social networking, right? And then some call/SMS stuff to prevent them from having to use their own phone line. Those are all non-PHI use cases. Well, now they’re tacking on PHI use cases. And that inherently has to be enterprise in nature because Dr. Smith, by and large, can’t sign a business associate agreement on behalf of Mount Sinai and give access to Mount Sinai’s patient data.

That tension of the subjugation of providers to increasing layers of hierarchy in the consolidation of providers in America means that historically PLG products have struggled or just not been really possible. We all want the Figma of healthcare and now we have one.

But really you’re just seeing them mature into enterprise because you have to do the harder, more valuable things. You kinda need business associate agreements and to sign agreements with institutions in America in terms of healthcare. And so that tension’s there. And I’m curious if they run into that as they try and offer these products and still maintain their roots as PLG, but also offer the really meaty stuff.

Brad Thorson (09:55) I just want to circle back — I think Pryce just came up with two incredible business ideas. Pryce, I think you’re suggesting UpToDate should get into the IAS space and use patients as their sales channel to providers. Pull down your records and then UpToDate can tell you exactly what to drop into MyChart to ask for something.

Brendan Keeler (10:23) Well, here’s the thing — OpenEvidence had patient-facing capabilities. They got rid of it. They got rid of it because it commoditizes themselves in some way when the patients can go and access that clinical information and it dilutes their ability to attribute ads and decision-making for pharma. And so I’m curious if they try and relaunch that in some capacity, but at the end of the day, we’re just sort of putting LLMs over the corpus of scientific information in America.

But like if I’m a doctor and I can go just be a doctor or access it as a patient, maybe I do that, to avoid that. So it’s just a weird — that business model, that third business model of patient-facing clinical decision support, which I want for my potential thyroid thing. Like I want to go look it up and understand the same way my doctor does.

Brad Thorson (10:52) Isn’t that what the economy is right now?

Brendan Keeler (11:17) Can you have both? Can you have your cake and eat it too? They’re seeing if they can have their cake and eat it three in terms of patient-facing, PLG, and enterprise.

Pryce (11:27) Eat it three.

Pryce (11:29) Yeah.

Brad Thorson (11:30) Also Pryce, we should expect an announcement shortly — if OpenEvidence is not working on it — that they find a clinical trials enrollment partner, right? Because that feels like the obvious next thing to slap on here. Hey, we understand the clinical pathways and the relationship to drugs. We can help get prior auths done so that patients get on these drugs and we can help with the discovery and development.

Pryce (11:31) Yeah. Yeah.

You know, we are taking a big leap here. Just to be clear, when I first read “Mount Sinai to integrate OpenEvidence AI enterprise-wide,” I’m like, so there’ll be a SMART on FHIR window in Epic where you can read about lymphoma, like recent lymphoma studies, right? But I’m expecting that they use this as a wedge to say, well, we don’t have this yet, but if you let your providers launch the SMART on FHIR app and they can read my content, but you also let me read the patient’s chart, then it’ll be easier for me to serve what’s relevant to you. And then if you let me read what the provider orders, I can make clinical decision support recommendations in real time. And before you know it…

Like I said, we made a jump from right now — this has nothing to do with PHI and they’re putting it into an EHR — and we’re assuming that they’re going to start letting actual chart data influence their care provision and their clinical decision support and then eventually their models or their business motion. But yeah, I don’t expect that to happen next month. We’ll see.

Brendan Keeler (13:03) That’s why they need someone who can help them do deep bi-directional integration work. Nadler, you know where to find us. I got one more thought here, which is they are shipping so much. They must be adopting LLMs to accelerate — not vibe code, but to accelerate development.

Pryce (13:06) Yeah.

Brendan Keeler (13:22) The marginal cost of development is dropping and you can see it with companies like this that you’re just like, how are they doing an announcement of this magnitude every month? And I think it’s a wake-up call for everyone in the industry that if you’re not adopting real Claude Code type products or Codex type products in your institution, you’re behind because you can really expand your roadmap as they’re very clearly doing. It doesn’t mean all these shots on goal are gonna work, but clearly they’re shipping a lot with their war chest of money. And I think it’s because behind the scenes they’re using LLM-assisted development practices.

Pryce (13:58) And to me, that’s a double-edged sword. I’m far from an expert in training AI models and understanding differentiation there. But sometimes I hear about things like this and I’m a little bit like, well, if this is an LLM wrapper on the corpus of scientific research that maybe is otherwise accessible, how quickly could an OpenAI or a Claude or a Doximity replicate this? They can do all this so fast, and so can everyone else. What is the — this is like when Americans moved west and people were rushing into Oklahoma. The Sooners. Getting dysentery.

Brendan Keeler (14:36) Yeah!

Brad Thorson (14:26) Yeah, I mean… Manifest Destiny.

Well, I think that’s why the sales nexus, the enterprise sales motion, is the important thing. Because once you have that space, once you’re in that workflow, it’s easy to bring partners along and just say, hey, we’re going to take care of this, because they have to fight for integration priority. That is the…

Pryce (14:49) Yeah.

Brad Thorson (15:02) The ability to quickly roll out a new feature means that sales is — this is great for me — sales is quickly becoming far more important than product and engineering. So you guys now work for me, which is great.

Brendan Keeler (15:15) Shots fired. Shots fired. One thing there is — in the PLG market, “Competition is a click away” is the saying. And that’s true, but look at Google. On the corpus of information available on the internet, we can go build a search tool. And yet 80% of people use Google. And so that’s why they’ve always positioned themselves as the Google of clinical evidence.

But I think they look at it and they’re like, s**t, Doximity is shipping exactly that, and others are shipping competitive products. So we need to lever over into enterprise so that competition is a contract away. Competition is a two-year, three-year contract away. That’s a moat. And that’s the moat that they jealously look at UpToDate every day and go, I wish we had that, to prevent the existential dread. So I think it’s astute to call that out by both of you.

Brad Thorson (16:03) Here’s my galaxy brain take for this podcast. If anybody can build this — well, I am constantly frustrated with getting my GLP-1 from my excellent PCP and his very responsive staff, but it takes — there was nobody making sure that I’m getting that drug that is coming from their 340B pharmacy and making them a ton of money, except for me. And if I wasn’t invested in getting my healthcare from an unnamed institution here in New York City, it would be really easy for me to just go online and find somebody who has a consumer experience to do that.

And it turns out we now know that the cost of developing that is $20,000 because the New York Times is giving MEDVi maybe too rosy of coverage for what they’ve built, but allegedly generating — was it $1.8 billion? Is that right? In revenue?

Brendan Keeler (16:58) Yeah, yeah. But if you think about it, their operational costs are quite high. So MEDVi is one of many front ends on OpenLoop, a sort of white-label telehealth provider that allows for you to set up a provider practice of sorts with any branding you want.

Their operational costs — a large part of whatever, if 1.8 is true — much of that is going to pay OpenLoop and pay for costs. But make no mistake, they’re making a bunch of money.

Brad Thorson (17:31) Yeah, but they’re competing against brands. 30 Madison got bought. They’re brands who had to put together all of this infrastructure. We didn’t have the idea of a 50-state PC that was focused on telehealth. It took a decade of digital health pushing on that door to develop it. We didn’t have the idea of mail-delivery compound pharmacies. There’s all these things that had to go in place. And then the part that really blows my mind is the cost of development of the website. It’s a form, right? They’re gathering information, they’re shifting it over to OpenLoop who’s providing an asynchronous visit, and then a drug is showing up at the patient’s door. Everything is LLM generated. They’re not hiring actors.

Brendan Keeler (18:15) Have you seen the form, by the way? It’s like, what’s your height? And then there’s six options or ten options that say 1, 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10. And then what’s your number of inches? And it lists them all out. It’s a UI atrocity. It’s like a war crime. So yeah, maybe LLM generated. Also not the ideal flow. But somehow, through a variety of tactics, converting people.

But Pryce, you had something you wanted to say.

Pryce (18:40) Well, I was going to say — yeah, we changed this from OpenEvidence at Sinai to “you can vibe code anything now, including a $1.8 billion revenue business.” Shout out CMS, ONC — you’re doing God’s work because apparently there’s a lot of organic competition that’s shoving its way into these software ecosystems with their elbows, saying I have the right to that data as well and I’m gonna use AI to build my product. I’m gonna use AI and what my product spits out. So it’s happening. That’s what we wanted. And in some cases it might be a little bit sketchier than in other cases as we shift to the MEDVi conversation.

Brad, you were talking about PCs and I was just learning about PCs and what’s their counterpart?

Brad Thorson (19:30) MSOs.

Brendan Keeler (19:31) MSOs.

Pryce (19:32) MSO. Yeah. So explain to me the organizational structure of OpenLoop. How are these physicians staffed, and is the founder of MEDVi the one who is staffing all of these physicians or just leveraging their services to create his pipeline of prescriptions?

Brad Thorson (19:57) Yeah, I mean, think of OpenLoop — the front door of the MSO — as collecting a bunch of services that are needed to enable telehealth businesses, whether that’s licensing, an EHR or telemedical service, or the actual providers that are going to see patients. OpenLoop does not employ them directly. They contract with professional corporations.

And then those providers are delivering care under their own discretion. And they will continue to become — it is equivalent to like, I open a coffee shop, I use Square as my POS, and then after I’ve done enough sales, Square Capital can make loans to me because they know what my cash flow looks like. They’re just going to continue to hang tools on their toolbox, and a question arises — at what point does the collection of those tools start to look a little bit questionable?

Brendan, I don’t know if you want to jump in and touch on something you’ve written about.

Brendan Keeler (21:15) Yeah, I mean, this article came out and I’m like, man, this name sounds really familiar. We don’t do a ton in the GLP-1 space at HTD, with a few customers historically, but yeah — I’m ready for peptides.

Brad Thorson (21:26) You guys are just skinny by nature, okay?

Wait, wait — that’s the other part about the story that was crazy, is the speed at which they could — okay, they hit GLP-1s and then they rolled out hair loss and they just looked at any other business and were like, we can build a cheaper mousetrap, and just rolled. It was crazy.

Brendan Keeler (21:51) I think that’s the article I wrote last summer, because this lawsuit — like most things that prompt me to think about healthcare — a lawsuit came out against OpenLoop that alleged that they were masterminding this sea of fraud, these fraudulent websites across the internet that were spun up to prescribe oral GLP-1s. This particular compound is not oral. It can’t be consumed orally. Tirzepatide-megalutide… I don’t know. We can look at the article.

Brad Thorson (22:18) It’s blue time.

Brendan Keeler (22:19) But I am not a doctor. Not a lawyer. Not a doctor. And so I went back and looked at that article and lo and behold, one of the “shell websites,” “shell companies” that was named in the lawsuit — as in, OpenLoop set up a fake website — was this company MEDVi. And so we now know that’s not true, that there are one or two guys behind this. They are a real company making some amount of real money.

But that means that the allegations about fraudulence need to be directed probably at MEDVi and not at OpenLoop. They’re not named in the lawsuit, but there’s a lot of chatter on Twitter and some good threads. Rik Renard posted a great post breaking down that, okay, they’re making real money, they’re real — but there are tactics, things, the way they’re appealing to patients, that could be deceptive. And that’s fraud. Fraud is not the existence or realness of a company. It is: are you deceiving the consumer? They could be breaking — many people are pointing out that they may be breaking FTC, FDA, and other regulations and laws.

We’re not gonna adjudicate that. We’re not lawyers, we’re not judges. But there is plenty of banter about that out on the market today.

Brad, what were you gonna say?

Brad Thorson (23:38) It seems like one of the major issues is that many brands were marketing oral tirzepatide. The fact that the product catalog was the same across all these brands seemed like the part of that lawsuit that the prosecution was most focused on, because tirzepatide cannot be delivered orally as far as we know.

Brendan Keeler (24:00) It’s not trisibuclopetide. I think you’re right.

Brad Thorson (24:03) Why do I know how to pronounce these drugs? This does not need to be space in my brain.

Brendan Keeler (24:08) I just think one takeaway, and this was in the original article, is that the power of the internet is the ability to reach national and international audiences for trivial amounts of money. The marginal cost of building global or national businesses has dropped dramatically. And so if you and I wanted to set up a business doing fraudulent behaviors, historically it was like, okay, let’s go prescribe ADHD meds en masse — but we’re just doing it in our geography. We’re bound by geography. In the age of the internet, you can spin up and reach entire audiences at a national scale instantly. And so long as you can utilize that potential audience and get a meaningful percentage of it, the potential harms you can do are much larger, much quicker.

We’ve seen it with ADHD meds and Cerebral back in the day, we see it rear its head here again, we’ve seen it with the opioid scandals. We see this all the time.

Brad Thorson (25:18) I think the difference is — the internet compresses the cost to distribute information. But whoever wrote the paper about the transistor that led to LLMs, we now have technology that greatly reduces the cost to generate content. And that collision of super easy to distribute and super easy to create the content to distribute — that’s what makes the acceleration of this business possible but also fascinating.

Brendan Keeler (25:51) And think about it — if we have AI doctors, imagine there’s some doctor behind the scenes of OpenLoop, but now we don’t need that infrastructure because we have AI doctors and they’re fully legalized. This highlights the need for guardrails as we go down that path, because all of a sudden, can you spin up a doctor and can you spin up a website? Great, you can do the full chain for marginal costs.

I don’t think I know the answer — potentially you guys know the answer — but it just shows that the harm can be done very, very quickly, very, very broadly.

Pryce (26:23) Well, in Rik’s post, it says that in their software, you can enter a birthday of February 31st, and then the app will tell you you’re quite likely to hit your goal weight of 200 pounds, even if you’re 7’11” and 350 pounds. So it’s like Shaq hoping to cut himself in half.

Brad Thorson (26:31) Thank God. Have you guys seen how thin Charles Barkley is?

Brendan Keeler (26:44) Yeah.

Brad Thorson (26:46) He looks great.

Brendan Keeler (26:47) Good for him.

Pryce (26:47) Well, he’s got the Ro.

You know what else this is making me think of? That you can build things so fast — the law and the repercussions of fraudulent activity or poorly designed software and clinical consequences now lag how fast you can build it and distribute it. And it’s making me think of how executive orders keep on happening in our country. And then a year later, we find out — we can’t erase the last year, but that wasn’t, you can’t actually do that.

There’s a lot going on in the world right now that’s like, boom, the internet plus LLMs lets people create so fast that we’re having trouble keeping it safe. And sometimes it’s awesome. It’s productive. It should be a release valve on the healthcare system, which is way overburdened. It should be deflationary. I was listening to the CityBlock CEO, Toyin, speak about this.

Brendan Keeler (27:27) How can we keep up?

Pryce (27:49) On the HTN podcast — you want to see these things be deflationary in healthcare. And instead, oftentimes they’re used by folks who are like, well, how quickly can we prop up a lot of profit? And so we’re seeing a lot of inflation instead of a release of the burden of not having enough providers in the country. Instead it’s like, well, for the providers we do have, can we help them up-code all the way? So the government owes everybody more money. Anyway, this is just another example of — I don’t think this is helping the crisis that we’re having.

Brendan Keeler (28:25) I had posted nine months ago, twelve months ago, where I was just feeling that exact thing. It is far easier if you’re an entrepreneur to make money off of making new money versus reduction of cost. It just is. And so the technological innovations we see go towards activating healthy consumers and patients to do new things, to spend more money a lot of times.

Even the patient empowerment stuff we see via the CMS HealthTech ecosystem — all of a sudden you’re activating the healthy middle that never engages in their health. That’s really good, but the short-term effects of activating this population to use more healthcare is gonna increase costs. More people that were just not doing things — which probably long-term is bad for their health — well, if they’re utilizing all their benefits and spending out of pocket on all these different things, that’s more cost short term.

And so I got kind of depressed a while ago because of that, because I was like, well, how are we ever going to fix this? And maybe Chris Klomp is the answer. He’s being thrown around all over the CMS as the person who’s going to make things deflationary. And I do have faith in him.

Brad Thorson (29:46) Yeah, we gotta give the law heads what they want. The people come here for the wonkery. Let’s get — is there a new acronym?

Brendan Keeler (29:46) Let’s segue in, given the Chris reference there.

For wonkery. Wonkery. Pryce, what are you hearing?

Pryce (30:01) Well, we’re back. We are so back. We are the ONC again. The HHS, Department of Health and Human Services, has many offices within it. One of those is the Center for Medicare and Medicaid Services, which uses a lot of the U.S. budget. Another one — much smaller and maybe I would say scrappier — is the Office of the National Coordinator, which was first named the Office of the National Coordinator for Health IT when Bush W had created it with an executive order. And then the last Biden administration changed it to the ASTP. So if you’re familiar with that acronym, that was the Assistant Secretary for Technology Policy. I’ve got my ASTP name tag right here. Amazing logo for the ASTP.

Brendan Keeler (30:47) Vintage stuff. Hold on to that. That’s gonna be worth a lot.

Pryce (30:56) I got my vintage Redox swag.

Yeah, this is gonna go on eBay in like 20 years. Holographic ASTP name tag.

Brendan Keeler (31:04) If they were smart — look, they don’t have much budget. They get 50 million, ever since Bush. If they’re smart, they would have sold swag at the ASTP annual meeting. That was a golden opportunity. They know this is coming. They know they’ve been working on it. They could have sold it. Everyone would have bought it. Problem solved. Deficit solved.

Pryce (31:18) Do we think — is it legal for government offices to become like a…

Brendan Keeler (31:23) What has legal ever been a problem for this administration? We’ll figure it out in court. The t-shirts. Should we sell the t-shirts?

Pryce (31:31) I was thinking we should get Dr. Keane to do a collab with Supreme or something. Just super expensive clothes with ASTP — or now ONC — on them. That would be great.

Brendan Keeler (31:44) It’s like the original LLM era a couple years ago where the Pope had the puffy jacket on. You know, we should do that sort of thing, but ASTP.

Pryce (31:52) Yeah. Super swag.

So with the change of this office from its name being the ASTP back to being the ONC, what else is happening? They divvied up some responsibilities.

Brendan Keeler (32:08) It’s really not that much of a change. What Micky Tripathi did in summer 2024 is he pulled together a few other divisions so he could do more with AI — basically that was his goal. He had the chief AI officer or something as part of his title or under him, similar C-suite type people within the agency. And now they’re kicked over to another part. So it’s reorged out, and their mandate and mission doesn’t change.

Even the verbiage that Micky Tripathi added in that change is maintained. So it doesn’t change much. And historically, I wrote a post about this, but almost every head of the ONC has done a reorg or multiple reorgs. Usually Democrats have added more sub-agencies and things like that, and then generally Republicans, especially Trump, tried to slim it back down.

So it’s not crazy. And if the pendulum swings and Democrats get elected, guess what? Maybe we see similar additions to the ONC. I don’t know if we’ll do a name change again. But the ONC, let’s go through it. Office of the National Coordinator versus Assistant Secretary for Technology Policy. The former is better. Objectively better. ONC versus ASTP.

Brad Thorson (33:31) ONC is easier to say for sure.

Pryce (33:35) ASTP way better. ASTP’s logo is way better. No offense.

Brendan Keeler (33:38) Wait — hot take — you like Assistant Secretary for Technology Policy better than Office of the National Coordinator?

Pryce (33:46) I always liked saying — I don’t know, I think those words roll off the tongue if you can say them quickly. I also loved saying, oh yeah, hanging out with Steve Posnack is like hanging out with the assistant to the Assistant Secretary for Technology Policy. You get a little bit of The Office vibe. So I’ll miss those jokes.

Something else that happened — I’ve got a friend that works at the ONC and I found out that he’s within the Office of Policy. That was historically called the O-Paul, I think, internally. But they just changed the name of that to the Office of Programs and Implementation, which I think should be called the O-PIMP now. So they’ve changed that name and I’m a huge fan of that change if we want to start abbreviating it.

Brendan Keeler (34:34) I think we should. This administration has also been really focused in the CMS world on things like ACCESS and fun backronyms. Why not the ONC? Let’s dial it up here.

Pryce (34:42) Backronyms, backronyms.

Pryce (34:49) What do we call it? Oh gosh, we’ll come up with a good name.

Brendan Keeler (34:52) So we got a few minutes left. Do we want to cover anything else before we close out?

Brad Thorson (34:57) I mean, the people are asking, what is an HIN? And I think we have to tell them.

Pryce (34:59) Brendan, you wrote about this. Maybe you want to tell us what you wrote about and then I’ll start commenting on my thoughts.

Brad Thorson (35:08) I’ll just throw this in there, Brendan. I don’t really care about the Henry Schein case. I know you’re deep into it, but when you create grids, I’ll read every one of those posts. So if you could just lead with the grids, I’ll fight through the rest.

Brendan Keeler (35:09) Sure.

Brendan Keeler (35:18) Okay, the Excalidraw — that’s the tool I use, it makes it look hand-drawn. Yeah, Henry Schein versus Vyne is just a vehicle and a vessel for a very important conversation, which is: what is an HIE?

So why are we having that conversation when Vyne, a point solution, a clearinghouse for dental, and Henry Schein, an EHR for dental — neither of them on paper are what we think of when it comes to HIEs. Well, it’s because the point solution, looking to use the Cures Act information blocking rules against Henry Schein the EHR, was unable to because Henry Schein backed out of the certification program to ostensibly avoid information blocking burden.

Pryce (36:01) So just to be clear, there was an EHR who was certified by the government. And that’s important. Lots of EHRs do that because oftentimes you need to in order to get reimbursement from CMS and things like that. Lots of reasons to voluntarily certify your electronic health record. But if you do so, you immediately become susceptible — you are considered an actor as a developer of certified technology that could commit info blocking, which is really broadly defined as discouraging the exchange of electronic health information.

So unlike most other industries where competitors fiercely hoard data and don’t share it at all, within the healthcare industry, the Cures Act says you have to share that data because it’s the patient’s data and other providers need it. And so we’re seeing this expanding ecosystem of like, you better share that data or you better make APIs.

And you’re saying Henry Schein, being a dental EHR, had pulled away from being certified. It was after this lawsuit was filed, wasn’t it?

Brendan Keeler (37:04) Yeah, and that’s one of the things — I’m not a lawyer, but what seems obvious is that the behaviors that were information blocking occurred last March 2025. They were a certified EHR. They were a developer of certified health IT — Henry Schein. And so you could claim that those behaviors were information blocking. Then they decertified, they withdrew in August or July. And the case was in September. So behaviors after that are nebulous. But it’s like, why didn’t you go harder in the paint on that one? Because that seems like slam dunk stuff.

Brad Thorson (37:38) Yeah.

Pryce (37:39) Right. Vyne, who’s suing Henry Schein, didn’t call it out.

Brendan Keeler (37:46) Yeah, they did lightly in their opening brief and then in these transcripts they just talk about HIEs and HIEs. And we’ll talk about why they go there next, but instead — do the easy slam dunk, no nebulous definition route!

Pryce (38:00) So within information blocking, there’s three different types of actors. These three types of organizations need to be very careful that they’re not committing info blocking. One being providers. Not really a way to skirt around that — if you’re a provider, you’re a provider. The second being a certified developer of electronic health technology, which would include a lot of major EHRs. And the third actor type, which is very nebulously defined — as Brendan loves to pull apart — is health information networks.

Brendan Keeler (38:40) HIE slash HIN.

Pryce (38:41) Okay, so the point being here, Vyne might have missed an opportunity to say, well, obviously they were an actor who could commit info blocking because they were a certified electronic health technology. And now they’re sort of saying, well, maybe they’re an HIE. This is an EHR that they’re saying was acting as a health information exchange. Let’s go into the details — what makes an HIE? Tell me about the preamble and all of that stuff, Brendan.

Brendan Keeler (39:09) So essentially when you’re exchanging data, there’s only three patterns. One is decentralized. Everyone’s a node on the network and you send from point to point. So that could be a network that sets rules for exchange between their participants — could be a health information network. And many of those types of networks — DirectTrust, Datavant, Carequality — those are all point-to-point between nodes. Those could be.

Pryce (39:36) Meaning all of the nodes trust each other, but you don’t get all of the healthcare information in the world and put it in one centralized server. Instead, the network is that you have a phone book, basically. And everyone in that phone book has a cert that proves, I’m in the phone book and you can trust me.

Brendan Keeler (39:57) Yeah, in the preamble they mention — they carve out and the ONC says, actually, if you’re doing bilateral exchange between two parties, then you’re generally not going to be an HIE/HIN. And so most of those networks with that topology, even if routing through a central thing like Datavant or something, say we’re doing bilateral exchange and we’re good. We’re not an HIN because we’re not storing the data. We’re not facilitating a fan-out.

And so the other end of the spectrum is what we think of when we think of state health information exchanges — stored in a big database. Everyone pushes data up and then when they need it, they pull data down. That model — that’s what Henry Schein is actually saying. Well wait a minute. We, as an API provider with an API program — people push data up to us, different apps that don’t know each other, to a single provider’s system, and they can pull down the data between them. One app pushes up, another can access it.

And so Henry Schein is saying, no, no, no, that model — we’re not an HIE/HIN either. But if that’s right, then state HIEs of that model aren’t HIEs or HINs. And so the only remaining class of network that would actually fall into the definition would be ones where you send up a query and it goes to many participants, right? One to many, inherently not bilateral.

But then at the end of the day, you just keep squinting at this. And I bet you every HIE, HIN, EHR — they look at this and their lawyers say, we’re not in this definition. And that can be fine. But right now it’s very ambiguous, because if Henry Schein is wrong, then everybody is an HIE or HIN if you offer an API.

Pryce (41:52) If you offer an API and have multiple parties connected into you and you receive or share or reconcile the data, yeah, I see what you’re saying.

Brendan Keeler (42:03) Yeah, where is the line? I don’t like this one, I hate it, because it’s so infuriating. And so in two to three weeks, we’re going to have a judge make the first call on what’s an HIE/HIN in this case. And that’s what’s important. That’s when we know if non-certified EHRs get looped in. I swear to God, every clearinghouse, every ADT network, every network in America — their lawyers are hyper-focused on this case, because it could draw them into actor status.

And if they’re not paying attention, they better be.

Pryce (42:34) Do we think this judge who’s going to make this decision has clerks or is he or she themselves calling the ONC and being like, what were you writing about here? How should I interpret it? Is that something they do? Because there’s so much ambiguity.

Brendan Keeler (42:49) Yeah, the judge is showing a really strong grasp of these concepts. They’re thrown all over the board. They are federal judges.

Pryce (42:58) I think they’re subscribed to Health API Guy. It’s crazy.

Brendan Keeler (43:03) Yeah, I haven’t seen any of those domains come in. But he shows a strong grasp. He’s showing a very traditional view on computer fraud and abuse, the CFAA, which is what Henry Schein is accusing them of. And he’s really diving into the bilateral thing when interrogating Vyne. But at the same time, sometimes judges go really hard in the questioning and then they go and read the statute and the guidance and stuff that the agencies have released.

I don’t know if they phone them up. I don’t think they do that. I think they generally rely on public artifacts and the law. And they’re gonna make a call. And he could make a call that really redefines this line. So we shall see.

Pryce (43:50) Well, one more question — how would that redefine the line? Is it now legal precedent, and would that only be in Maryland, or would that be federal? Is it more like, I feel more comfortable making a decision like this because this judge made that decision in Maryland? Or is it, no, I can use this as a legal artifact from now on?

Brendan Keeler (44:09) It’s both, right? It is limited to whatever the district court covers — Maryland and maybe some other areas. And then if it’s appealed, you see broader applicability. If it’s appealed to the Supreme Court, that’s when you get pretty uniform stuff. But yeah, absolutely there’s regionalization.

But just one precedent allows for someone to point from a favorable jurisdiction. Someone in California can point and say, hey, look what happened in Maryland, and we have laws that kind of overlay on that. They can’t point to it as pure precedent, but then what you’ll see is — Vyne filed in Maryland, not in Utah, which they could have filed in because both parties have offices there. And that’s a very strategic choice to use the Real Time Medical / PointClickCare precedent.

So we could see similar dynamics if it breaks a little bit towards Vyne or fully towards Vyne.

But we are over time, so I think we gotta wrap. This was a fun one. See you all later.

Brad Thorson (45:08) Yeah, we’re gonna go back to our normal jobs. See you guys.

Pryce (45:12) Happy Good Friday! See ya!