The Information Exchange

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 represente…

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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 …

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Healthcare’s biggest conference has come and gone, so the team is back (down a man or two) to bring you some updates there, as well as every twist and turn of a very busy week in the courts.

* HIMSS 2026 felt smaller but more productive…and the sentiment was surprisingly pro-HIMSS over ViVE

* AI headlined as expected, but the real conversations were about data normalization and cleanliness underneath the agentic hype

* Epic subtly debuted Willow Pharmacy Network, a new “With the Patient at the Heart” product that could signal a long-term play against Surescripts

* The American Association for Disability Justice filed antitrust and information blocking claims against Epic over MyChart’s fragmented login experience

* A surprise stipulated agreement from GuardDog Telehealth reshapes the Epic v. Health Gorilla case ahead of April’s motion to dismiss hearing

* Ryan recaps a guest lecture at Johns Hopkins and the malpractice risk thread that explains more about healthcare’s data reluctance than most people realize

Plus we mentioned rumblings of a bonus class action lawsuit, which came true later that afternoon as Fox, Edward v. Epic, Beaudreau, Edgar v. Epic, and Banh, Priscilla v. Epic all kicked off. While on paper it’s not great for Epic, there’s potential upside if they’re able to consolidate effectively.

Relevant Articles

* Epic's AI announcements: The baseline announcements from Epic at HIMSS which were very AI focused

* Introducing Copilot Health: Microsoft’s buzzy announcement of a consumer health product powered by HealthEx, paralleling ChatGPT Health and Claude Health

* Epic Beyond the Provider Empire: This article explained Health Grid products and waxed hypothetical about a future pharmacy oriented product, which we saw at HIMSS via Willow Pharmacy Network

* Down the Disability Data Rabbit Hole: The strange fruit of minot investigational journalism into a beef tallow influencer’s medical records videos, including one that targeted Epic

* Ryan’s post on data quality: Pipes are only half the battle. As access becomes ubiquitous, it’s about what you do with it (if you even can).

* AADJ v. Epic: The unexpected lawsuit that launched during HIMSS with disability advocates and patients claiming antitrust, information blocking, and disability violations, which explained Mr Beef Tallow Influencer above

* Epic's TEFCA IAS plans: This details their MyChart Central / unified login plans, which seemingly contradict the AADJ claims

* Epic v. Health Gorilla: GuardDog Rolls Over: The bombshell of one of the defendants in the Health Gorilla lawsuit turning tail and entering into consent by admitting various violations

* Epic Lawsuit-ception: After recording Friday, the lawsuits we alluded to came to light as three separate templated class action lawsuits were filed against Epic for inappropriately disclosing PHI to Health Gorilla.

Chapters

* HIMSS Recap: Overall Impressions (00:00) - Brendan’s on-the-ground take from HIMSS in Vegas — attendance trends, booth culture, the cat pit, and general sentiment versus ViVE.

* AI Announcements: From Chatbots to Agentic (02:48) - Epic’s Art/Penny/Emmy rollout, Microsoft’s patient access chatbot with HealthEx, Agent Factory, and the gap between clean demo environments and messy real-world data.

* Data Normalization and the Infrastructure Layer (05:19) - The wave of companies tackling data cleansing, parsing, and augmentation as TEFCA and information blocking rules make data movement easier.

* The Under the Radar Announcement of Epic’s Willow Pharmacy Network (06:16) - A new “With the Patient at the Heart” network product targeting specialty pharmacy workflows — and what it signals about Epic’s beachhead strategy into pharmacies and potentially e-prescriptions.

* New Lawsuit: Disability Access and MyChart (09:07) - The American Association for Disability Justice files antitrust and information blocking claims against Epic over fragmented portal logins, plus analysis of why the legal claims face uphill battles.

* TEFCA, IAS, and Health Tech Ecosystem Updates (16:23) - Kill the Clipboard demos, digital identity with CLEAR and ID.me, and Clover Health joining as the first payer in health information networks (plus the Wall Street Bets subplot).

* Ryan’s Week: Teaching FHIR at Johns Hopkins (20:22) - A Q&A with grad students on interoperability trends, wearable data, and the signal-to-noise problem with smartwatch data flowing into clinical workflows.

* Malpractice Risk as a Hidden Driver (22:28) - Why the fear of liability shapes provider attitudes toward data volume, RPM, AI summarization, and even HTI-5’s auditability certification debate.

* Epic v. Health Gorilla: The GuardDog Settlement (26:35) - A surprise stipulated agreement from co-defendant GuardDog Telehealth changes the dynamics of the case, potentially undermining Health Gorilla’s procedural defenses ahead of the April hearing.

Transcript

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

Ryan Tucker: So we are back with the Information Exchange — two out of the four players here, but we’re going to go strong. I would love to start with a HIMSS recap from you, Brendan. I was pretty busy myself on the other side of the country. Didn’t make it out to HIMSS. Saw some news, but I would love to hear your take. What happened?

Brendan Keeler: Yeah, quite a lot. Have you been to HIMSS before? I don’t know if we’ve ever synced on this.

Ryan Tucker: Yeah. So I went when I was with Epic, I think about two years in, and I was in the basement doing an Interop Showcase or whatever it was called, where I ran the same script I think 45 times in two days. So that was a very repetitive, not a great experience just in terms of personally needing to do the job there, but it was fun and Vegas was fun. It would be a very different experience now. I’ve been able to go to ViVE since then and things like that, but I haven’t been back since that one showcase.

Brendan Keeler: You go to Vegas too many times and you’re in the Venetian over and over again, it just blurs the years. Booth working is different than sort of rogue agent parachuting in and having 12 meetings a day, which is the way that we typically operate when we go to HLTH and ViVE. You can more easily find ROI for certain companies if you’re setting up meetings, going and ad hoc meeting people — versus a booth that really is six figures or above as soon as you have something hanging from the ceiling.

Our colleague Brad and I went out, had a ton of great meetings. Overall it felt a little smaller. Since the sale of HIMSS to Informa a couple of years ago, we’ve seen a contraction from 35,000 or whatever it is to 30. And I feel like it may have trended down — the booths were a little more spread out, it felt more spacious in terms of the throughways and stuff like that. There was all the requisite weirdness in terms of people going a little too far with marketing and putting stuff out there. There was one group that had a robot hand on their head that was going like this. That was probably the highlight of weirdness.

But it was good. It was very productive. A lot of sentiment was “this is way better than ViVE,” which you don’t expect. They had a cat pit instead of a dog pit. So ViVE typically has all these puppies you can go play with, and they had kittens. I didn’t get a chance to do that, but it seemed pretty cool. They’re trying to be competitive with ViVE in that regard. Are you more of a cat or a dog person?

Ryan Tucker: Definitely a dog person, but I would pet a cat.

Brendan Keeler: Yeah, kittens are still cute, fluffy — anything to deal with the hangover of being in Vegas. But beyond that, what did we see? AI, all the things, right? Epic, if you look at all the press releases that went through CNBC and Modern Healthcare, it was just all Art and Penny and Emmy for Epic — their AI announcements. We had consumer-facing AI from Microsoft…

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Well, well, well. March came in hot. I was out thanks to the unending vortex of daycare-induced illness that plagued my home all February. So Pryce, Brad and Ryan had to carry the load - and carry it they did.

On top of that, they tackle:

* Jack Dorsey’s Block layoffs: 10,000 down to 6,000 at a profitable, growing company, because the AI tools made the headcount unnecessary

* The SaaS-mageddon question: are we watching the first domino fall, or is the “AI replaces everyone overnight” narrative still overblown?

* FDA deregulation and Harrison AI’s push to skip premarket review: speed vs. safety in a domain where the stakes are human lives

* Glyphosate, Roundup, and the MAHA contradiction: how do you push preventive health on one hand and subsidize empty calories on the other?

* The ACCESS Model’s brutal reimbursement math: $15/patient/month doesn’t exactly scream “invest in behavioral health infrastructure”

* A galaxy brain segment on whether AI opens the door to a thousand little EHRs (spoiler: the interop team would never sleep again)

Relevant Articles

* Steve Posnack’s LinkedIn post: Brad mentions the episode was “inspired by” it.

* Jack Dorsey’s post on X: About Block’s reduction in force from ~10,000 to ~6,000 employees, specifically citing AI/agentic tools as the reason despite the company being profitable and growing. Ryan describes it in detail.

* An Epic Anthropic Alliance: Pryce references something Brendan “just wrote” about discovering Epic is leaning into Claude usage on campus for internal code development.

* THE 2028 GLOBAL INTELLIGENCE CRISIS by Citrini Research: A hypothetical 2028 scenario where AI-driven unemployment triggers economic collapse, mortgage market failure, etc. Pryce notes there are “cracks in its argument” and it’s somewhat sci-fi in tone.

* AI Transformation Is a Workforce Transformation: Brad cites a stat breakdown: 10% is the model’s capabilities, 20% is what you’re introducing it into, and 70% is operationalization/teaching people how to use it.

* Harrison AI’s FDA exemption request: Ryan discusses Harrison AI (and possibly others) seeking exemptions from the FDA’s pre-market review process for AI devices.

* Trump’s executive order on phosphorus/glyphosate production: Pryce references a signed order increasing domestic glyphosate (Roundup) production, and RFK’s subsequent cosigning of it.

Chapters

* Introduction and Conference Takes (0:00 - 4:30): Brad recaps ViVE, where every booth pitched identical agentic AI solutions. Ryan and Price weigh in on the real value of industry conferences.

* Block Layoffs and the AI Employment Shockwave (4:30 - 9:00): Ryan breaks down Jack Dorsey’s decision to cut 4,000 employees from a profitable, growing company because AI tools made them redundant. The group asks: is this the first domino?

* AI Hype vs. Economic Reality (9:00 - 14:00): Price and Brad debate whether AI will pull the rug out from the economy or diffuse slowly enough to avoid catastrophe. Brad drops a BCG stat — 70% of AI implementation is workflow, not the model — and predicts an explosion of custom software.

* AI in Healthcare: Scribes, Code, and Patient Safety (14:00 - 19:30): Ryan draws a line between AI that removes friction (scribes) and AI that replaces humans writing safety-critical code. The group reflects on Epic’s patient safety escalation culture and whether AI-generated code can meet that bar.

* FDA Deregulation and Harrison AI (19:30 - 24:00): The group examines the FDA’s loosening of premarket review for AI devices, distinguishing between probabilistic recommendations that need scrutiny and interface-level AI that may not.

* Glyphosate, Nutrition, and the MAHA Contradiction (24:00 - 30:00): Price goes full gardener, connecting Roundup subsidies to nutrient-depleted industrial farming and questioning how HHS can push preventive health while enabling cheap empty calories.

* A Thousand Little EHRs? (30:00 - 33:00): Brad asks whether AI enables a proliferation of bespoke EHRs. Ryan sees job security for interop folks; Price would rather see a million provider groups than a million EHRs.

* Competition, Single Payer, and the ACCESS Model (33:00 - 37:00): Ryan puts on the socialist brain to argue healthcare competition doesn’t optimize for health outcomes. Brad closes hot on the ACCESS Model’s $15/patient/month reimbursement math and what it means for behavioral health.

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.

Brad Thorson [00:00]

welcome to another edition of the information exchange sponsored by HDD Health. Can you believe our employer is sponsoring us? I am back from Vive this week and this is a very special edition inspired by Steve Posnack’s LinkedIn post, no Brendan Keeler today. So, boys, you got a lot of explaining to do for me today.

Pryce [00:27]

This is a facial hair only podcast today. Sorry, Brendan.

Ryan Tucker [00:32]

that’s right.

Brad Thorson [00:34]

I wanted to kick off just with I think some things I saw at Vive are gonna be Well, I missed all the big announcements because everybody does their press announcements around Vive, but if you’re at five You don’t have time to check your RSS reader or linkedin But you know I would say my takeaway it was great to see my good friends got to meet some new people But because we’re gonna be spending a lot of time talking about AI My concern is every booth was about agentic AI And the marketing copy is essentially the same from booth to booth to booth and so, know, one of the problems with using AI is it can pull everything towards a mean and I don’t know if anybody wants to hire me to help them run their conference. I probably don’t want that job but I’m a little concerned that our conferences are starting to look all the same and that’s gonna make it tough. If you gotta go on the conference circuit and there’s not a whole lot that changes, it’s not gonna pull you in. But maybe that’s the direction we’re heading because this week felt like it was all about outside of Vive, the AI,

Ryan Tucker [01:55]

get into the ARR again, which is very relevant to this, I just wanted to ask you, since you went to Vive, we also went to the ASTP annual meeting event very recently. I’m sure we’re sending folks to HIMS. Do you feel like it’s really about the content that’s shared?

Brad Thorson [02:11]

we are.

Ryan Tucker [02:19]

during that event. course, somewhat the conversation stems around there. Do you think it’s really just an excuse for folks who are in this industry to get together in person and have some conversation? Like that’s the most value I’ve gotten out of these things is most of us work remote nowadays. We don’t really come together outside of like our internal company workings, our working with our client. And to me, it’s like a good excuse for everybody to get together in a room, have some drinks, you know, go over what’s on their mind from that time period, not necessarily what the latest and greatest announcements that came out put on by the conference and the organizations attending.

Brad Thorson [03:04]

Yeah, I mean, think they’re depending on the type of conference. mean, the ASTP having an annual conference is a nice forcing function for for them to like put together everything that they want to communicate. Same way I feel like when we went to open an epic, that was like, you know, a singular organization had a North Star and that felt like a forcing function. Industry conferences. mean, God, I don’t know how many have been to at this point. I think that there are three types of cohesions that they create that are valuable. One is like, yeah, I can see you guys, I can see other people that I’ve worked at our previous companies or have partnered with and like that brings us closer, it reminds us that we could work together. That’s the positive thing that I get out of it. I think it’s also, you know, for executive level atte…

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Well, hot damn. Would you look at that? February slowed down. Luckily for everyone, we at HTD sent the full squad to DC for the ASTP’s Annual Meeting, which was quite the event. Did they announce a bunch of new things? Absolutely not. But that’s not the fun of that kind of conference - it’s the nuggets and the teasers (and the people, of course)

On top of that, we tackle:

* Information blocking, antitrust, and the coming enforcement era

* HTI-6: the rule they didn’t announce but kept hinting at

* Conversational interoperability (COIN) and agent-mediated exchange

* The emerging questions around AI clinicians

Relevant Articles

* The 2026 ASTP Annual Meeting: From Policy to Practice by Bonne Fire

* Epic in the Crosshairs

* Open Data, Agents, and the Next Era of Prior Authorization in CMS-0057-F by Josh Mandel

* The Scribe That Launched a Thousand Takes (section on AI doctors)

Chapters

* Introduction and Conference Vibe (0:00 - 0:34): Brendan, Ryan, and Brad recap the ASTP annual meeting in DC, noting high vibes and the value of “hallway track” conversations.

* Info Blocking and TEFCA Growth (0:34 - 2:28): The group discusses the first notices of enforcement for information blocking and TEFCA’s “hockey stick” growth to 500 million record exchanges.

* ASTP Role and Regulatory Teasers (2:28 - 8:29): Brendan explains the ASTP’s history and identifies “teasers” for the upcoming HTI-6 rule, including a focus on anti-competitive behavior and dominant vendors.

* Future Standards: COIN and AI (8:29 - 12:07): Brendan defines Conversational Interoperability (COIN) as an AI-driven, language-first standard that could eventually succeed FHIR by handling flexible, non-deterministic data.

* The Rise of AI Doctors (12:07 - 23:02): Brad and Ryan analyze the Utah AI pilot and the broader trend of using LLMs for clinical decisions, weighing increased care access against the risks of scaling bad actors.

* Closing and Regulatory Deadlines (23:02 - 23:43): Brendan closes with a call to action for listeners to submit comments on HTI-5, USCDI V7, and the AI and Diagnostic Imaging RFIs.

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.

[00:00] Brendan Keeler: Look at us. Here we are. It is the podcast—the “Not-A-Podcast”—The Information Exchange. We have Ryan here to join us; Pryce is working hard. So Ryan’s joining Brad and I to talk about the Assistant Secretary for Technology Policy’s (ASTP) annual meeting in Washington, DC, which we sent the full crew to. “Sent it,” as the kids say. What do we think? What are the big takeaways? What’s the vibe?

[00:34] Ryan Tucker: Longtime listener, first-time caller. Vibes are high. We sent the team in full force. I personally felt that—and this is quite often the case for conferences like this—the times outside the main sessions tend to be the most useful to me. I think we should talk about the sessions first, probably the main thing I took away, and we can start maybe with the keynote. There’s starting to be some enforcement, if you could call it that, when it comes to information blocking, or at least notices have been sent out.

[01:06] Brad Thorson: Yeah, well, I’m just going to say I think that’s the biggest “pregnant pause long comma” in the entire thing. I mean, we’ve been waiting, but I would love to see some names. I definitely think we should circle back to info blocking, but keep going, Ryan.

[01:23] Ryan Tucker: Also, TEFCA is becoming more and more of a thing. I think they said 50 million record exchanges...

[01:30] Brendan Keeler: I thought it was more. I thought it was like 400 million now or something.

[01:33] Brad Thorson: No, 500 million and more than 70,000 participants.

[01:39] Brendan Keeler: “Hockey stick growth,” perhaps, is what was termed.

[01:44] Ryan Tucker: This was always a thing in Epic where we would measure record exchange. At some point, that’s not really the data point that’s interesting, but for an up-and-coming network, I guess that still makes sense in terms of sharing. I’m interested in how it all plays out with the Health Tech Ecosystem, but it is good to know that exchange is happening and that 70,000 organizations—I’m assuming that’s all of Athena coming on—is really just EHRs flipping the switch.

[02:28] Brendan Keeler: Let’s take a step back. For listeners who are like, “What is this conference?” or “Who is this organization?” The ASTP, formerly known as the ONC, is the health technology regulator in the United States. They oversee the voluntary certification program of EHRs. They oversee TEFCA, this health information network consortium. They oversee information blocking; their authority is derived from the HITECH Act and the Cures Act.

One interesting fact is that their funding has been basically the same through multiple administrations despite inflation. At the start of the Trump administration, people thought we might get rid of the certification program, TEFCA, or the ASTP entirely. That has not proven true. One takeaway from this conference was the ASTP saying, “We are still here. We are still doing our jobs”. Did you guys feel that as you wandered the halls of the Omni?

[04:23] Brad Thorson: I think there’s a lot of excitement because they’re good communicators. They’ve been very active in the last two months, which has created a lot of discourse. It feels like there’s a lot of anticipation for information blocking enforcement. Everybody’s excited, but you can feel the anticipation regarding the impact of CMS Aligned Networks and whether they’re going to increase TEFCA participation.

Key Technology Teasers (HTI-6)

[05:06] Brendan Keeler: When you go to these conferences, you listen for the “nuggets”. There weren’t many unplanned nuggets this time; they were very planned. One “teaser” was the surprise insertion of the FTC, DOJ, OIG, and ASTP joint panel to kick off “Information Blocking 201,” where they laid down the overlaps of their authority in stopping anti-competitive behavior. Reading between the lines, it felt like they were directing people to report anti-competitive behaviors, likely alluding to the market dominance of large software vendors like Epic.

Another teaser was the heavy focus on the future of technology and standards. They spoke about several technologies:

* FHIR subscriptions

* CDS hooks

* Bulk FHIR and bulk import

* COIN (Conversational Interoperability)

It’s hard not to imagine those being included in the HTI-6 Proposed Rule expected in the spring or summer.

[08:29] Ryan Tucker: Would you explain the COIN methodology?

[09:13] Brendan Keeler: COIN, previously called Language-First Interoperability, is a nascent type of data exchange. It’s “AI, baby”. Instead of sending a payload in a rigid, deterministic format that requires specific code to parse, you have agents that can handle arbitrary language payloads. Much like a phone call between a hospital and an insurer, agents can go back and forth negotiating and providing information. It could handle things like prior authorization workflows very flexibly. It really could be the heir to FHIR.

The Rise of AI Doctors

[12:07] Brad Thorson: Pairing COIN with things like the Dr. AI pilot in Utah is interesting. They had 22 million consults with a 99.2% treatment accuracy rate for diagnoses and prescription renewals.

[13:23] Brendan Keeler: The rise of AI doctors is upon us. The Utah pilot is for refill requests, which are simple, but it’s a seminal moment for computers making licensed decisions. There’s been a horde of AI doctors released recently—Verily Me, General Medicine, Function. It’s a sea change in mentality; people now trust LLMs enough to perform these roles where they didn’t trust deterministic logic.

[15:12] Ryan Tucker: It’s dependent on the scope of the workflow. Refills don’t need much background, but as you get higher in care complexity, these models might fail and you’ll need an expert provider. Bas…

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February is not slowing down. With Brad still on the road, Pryce and I announce the official name of this not-a-podcast: The Information Exchange! Shout out to Nathan from Availity for the inspiration here.

Beyond that, we cover a dense run of platform moves, regulatory signals, and courtroom skirmishes that all point in the same direction: tighter competition at the core of healthcare infrastructure:

* We dig into Epic’s ambient AI launch and what it means for third-party scribes,

* Why USCDI v7 is a real inflection point (appointments included), despite the competitive angles of exposing future care

* How imaging interoperability is finally getting regulatory attention

* A look at Veeva v. Epic and what non-competes reveal about where system-of-record battles are headed.

It’s the perfect plane ride fare as we all head to the ASTP Annual Meeting in DC this week. Can’t wait to see you there.

Relevant Articles

* The Scribe That Launched a Thousand Takes

* Apple Earnings and OpenClaw by Dithering

* Moats Matter Again by Travis May

* USCDI v7 and the End of Incrementalism

* Much Ado about Diagnostic Images

* SMART Imaging Access by Josh Mandel

* Veeva v. Epic: The Talent Battlefield

* The Veeva v. Epic Complaint

Chapters

* Introduction and Announcement (0:00 - 0:24): Brendan and Pryce introduce the podcast and announce its name, “The Information Exchange.”

* Weather and Personal Updates (0:24 - 0:54): Pryce talks about the weather in San Antonio and his excitement for summer.

* Discussion on Epic’s Ambient Scribe (0:54 - 3:31): Pryce and Brendan discuss Epic’s release of an ambient scribe and its implications for the market.

* Competition and Market Dynamics (3:31 - 5:25): They explore the competitive landscape, pricing, and the impact of Epic’s market presence.

* Antitrust and Information Blocking (5:25 - 7:19): The conversation shifts to antitrust issues and information blocking laws affecting the industry.

* Interoperability and Regulatory Environment (7:19 - 9:57): Brendan and Pryce discuss interoperability provisions in the US and Europe.

* AI and Future of Software (9:57 - 14:15): They speculate on the future of AI in healthcare and its impact on user interfaces and systems of record.

* USCDI V7 and Healthcare Data (14:15 - 24:29): The discussion covers the United States Core Data for Interoperability (USCDI) version 7 and its implications.

* Diagnostic Imaging and RFI (24:29 - 39:42): They talk about the diagnostic imaging request for information (RFI) and its potential impact on healthcare.

* Veeva vs. Epic Lawsuit (39:42 - 46:21): The episode concludes with a discussion on the lawsuit between Veeva and Epic regarding non-compete clauses.

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, ladies and gentlemen, we’re back. It’s Pryce and I; Brad is out on travel again. So, the dynamic duo. We have an announcement. This thing—podcast, pseudo-podcast, not a podcast—it has a name: The Information Exchange. Thank you to everyone who submitted. Prize money will be going out shortly. But as we exchange some information here, what should we start with, Pryce?

Pryce (00:30): Well, the first thing I want to tell you is that it is 83 degrees today in San Antonio. So we are back. I’m ready. I’m sorry to everyone else; they probably think I’m sad that I live in Texas, and sometimes it is, but today is Friday. I’ve got allergies because of it, but I’m thrilled and I’m excited for summer.

Brendan Keeler (00:36): Don’t flex on them. There are poor people in New York or whatever that are freezing their bums off.

Pryce (00:54): But you know what I am thinking about? A much colder place. A place where they just released their own ambient scribe—but don’t call it a scribe! According to Dr. Gerhart, it’s Epic’s release of Art. And I mean, it’s released. Is anyone using it already? Or was it just a press release?

Brendan Keeler (01:17): Yeah, they said they’re piloting it, I think with the usual crew in the Madison area.

Pryce (01:19): Okay. Group Health Cooperative? Thank you for delivering my first baby. Yeah, so that one’s really exciting for me.

Brendan turned me on to a podcast from Ben Thompson and John Gruber called Dithering. It’s like 15-minute episodes, and I’ve learned a ton about FAANG companies and their distribution. This release of an ambient scribe—from the company everyone thinks has the walled garden and all the healthcare data—it begs the question: Do all other ambient scribes wither away?

I think the answer is obviously not, but Epic does have distribution. Apart from functionality and integration, Epic has an MSA with every organization they’re trying to sell this to. They have the ability to make it a cheaper implementation because their system is already the source of record. Does that give them tailwinds? Yes. At the same time, everyone I know has an iPhone in their pocket and Apple Maps is way worse than Google Maps. I think with the evolution of info-blocking policy and the market, we’re going to see independent vendors be able to outperform incumbents on their own platforms.

Brendan Keeler (03:34): Yeah, I see optimism. If you’re a vendor, you’re not psyched because your goal is to operate in a space where nobody else is. But guess what? That’s not real for real problems. Good problems have many solutions, and Art is another one.

From a vendor perspective, you’d hope Epic doesn’t enter, but every EHR—except for maybe MEDITECH—is making their own scribe. Competition should be assumed. Information blocking means Epic better make their technologies available and not preclude competition on a technical level, or they’re going to be at risk of info-blocking. Another point is pricing: more competition means lower prices for providers, which is a positive. One manifestation of Epic behaving anti-competitively would be pricing competition out of existence, but they would be colossally stupid to do so right now.

Pryce (05:33): Specifically because that is what the state of Texas is calling out in their lawsuit against Epic.

Brendan Keeler (05:46): Right, so where is the bar? We know their pricing; it’s not per seat like many of these scribes. It’s a bucketed license of AI functionality added to your base Epic package. When does it become predatory? As a capitalist, I will always argue for the open market and competition leading to lower prices. It was inevitable this happened. The net result should be better for providers. It doesn’t kill these third-party scribes; they just have to keep doing the next thing.

Pryce (06:49): Healthcare is unique in that our industry has info-blocking laws. Meta, Google, and Microsoft are competitive, but they release software on each other’s platforms. Do they have more levers to block each other, or are they equally scrutinized by the FTC?

Brendan Keeler (07:19): They’re certainly scrutinized; all of them have active antitrust cases. Consumer technologies are different than horizontal B2B or vertical SaaS. In the US, there’s antitrust stuff, but not many interoperability provisions. In Europe, the Digital Markets Act specifically targets “gatekeepers” and says they must be interoperable and not self-preference.

Pryce (07:57): Wait, hold on real quick. Brendan is telling you this is super interesting, but when he went to join this podcast, he accidentally pasted a message about a court addressing a motion to stay on February 11th. Brendan is reading court cases—he’s built different.

Brendan Keeler (08:24): I’m built different! But that was about CureIS. February 11th, we’re going to get some decisions. I’ll buy the transcript and we’ll find some juicy stuff in the case against Epic.

Pryce (08:28): I’ll let you read that while I do something else. I want to think about the stickiness of systems of record. Dithering mentioned this week that with the proliferation of AI, you can kind of…

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Dry January has started out torrentially wet, at least in terms of health tech news. Brad is back from vacation just in time for us to break down the newest lawsuit and other comings and goings with Pryce and me:

* Epic’s case against Health Gorilla and why this one is going after mass-tort

* Anthropic (and OpenAI) entering healthcare through patient-directed data access

* Why nationwide exchange networks are straining under non-treatment demand

* What ambient AI and administrative networks (Abridge × Availity) tell us about where workflows are heading

As an aside - editing took a tad longer than usual, so apologies for the delay.

Relevant Articles and Posts

* Epic v. Health Gorilla: A New Fight Begins

* Pryce’s Excellent “Epic Lawsuit 101” LinkedIn Post

* Epic’s Tactical Strike Beyond the Grey Zone

* The Particle v. Epic Casebook

* Another One: Anthropic’s Healthcare Debut

* One Copilot to Rule Them All

Chapters

* 00:00 - Introduction and Overview of the Epic Lawsuit

* 03:07 - Understanding Healthcare Data Networks

* 07:57 - The Role of Health Gorilla and Other On-Ramps

* 12:46 - The Competitive Landscape of EHRs and On-Ramps

* 20:18 - The Ethical Implications of Data Usage

* 27:54 - The Need for Court Actions in Healthcare Networks

* 29:02 - Understanding Individual Access Services (IAS)

* 30:22 - The Role of Technology in Patient Data Access

* 34:41 - Collaboration Challenges in Healthcare

* 39:42 - Streamlining Prior Authorizations with New Partnerships

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.

Brad Thorson (00:01)Gentlemen, it’s been a while. I’m recovering from the flu, as you can hear, but I really enjoyed last week’s discussion. Sorry to have missed it. I thought we were going to talk about Anthropic’s entry into healthcare, but something bigger happened earlier this week. Pryce, talk to me about Epic and Health Gorilla. What’s going on?

Pryce (00:23)I posted on LinkedIn this week explaining the Epic–Health Gorilla lawsuit for beginners.

The background is that nationwide health data exchange networks have existed for a long time. For people newer to healthcare data portability—who may have just downloaded ChatGPT Health and realized they can pull their charts—doctors have been able to exchange data like this for decades.

The premise is that when you request data on these networks, you generally must be treating the patient. That’s the HIPAA “Treatment” purpose of use. These networks were built primarily for providers delivering care.

There are gray areas. For example, what about a provider-facing application that isn’t an EHR but is used by clinicians? The user is still a provider requesting data to treat a patient, but you start to see edge cases. Eventually, some uses cross into fraud—where no one is actually treating patients.

At their core, these networks exist so physicians can query each other for clinical data. Non-physician entities often try to join, not to sell charts on the black market, but for adjacent use cases like care management or analytics. Brendan, can you walk through the prior cases that set the stage here?

Brendan Keeler (02:29)In April and May 2024, Epic initiated a Carequality dispute—not a lawsuit—against Particle Health. Several Particle customers were cited, including Integritort, which focused on mass-tort use cases similar to what we’re seeing now. Another was Reveleer, which operated at the payer–provider boundary.

That dispute didn’t resolve, and Particle later filed antitrust claims against Epic in September in Particle v. Epic. That case focuses on business-associate applications connecting to EHRs on behalf of providers and being blocked.

This lawsuit is different. Until now, it was a category of one. It concerns nationwide networks being used for purposes outside their original design. The dispute centers on where creativity crosses into abuse.

Epic is not targeting gray-area use cases that many people might defend—like patient access, clinical trials, or value-based care. Instead, this case is narrowly focused on mass-tort data harvesting. Lawyers allegedly used the networks to identify patients with PFAS exposure and market lawsuits to them.

That use case has almost no sympathy across the industry. If the allegations are true, it’s clearly outside acceptable bounds. That’s why the case is structured this way: it isolates a behavior very few people will defend, unlike the broader debate over treatment versus adjacent uses that can do societal good.

Brad Thorson (05:48)Let me interrupt. I’ve learned this from working with both of you, but many people didn’t start their careers embedded in EDI or health data exchange. Can we briefly describe the ecosystem? What are these networks, and why do on-ramps like Health Gorilla exist?

Pryce (06:18)Historically, Epic created Care Everywhere so Epic customers could exchange data with each other using CDA documents for continuity of care.

Other EHRs responded. That evolved into networks like eHealth Exchange and CommonWell. The key point is that any node querying data must be trusted to be providing treatment.

Over time, these networks interconnected—Care Everywhere, CommonWell, and eHealth Exchange shared trust frameworks. Now we’ve moved into TEFCA, with QHINs acting as intermediaries. Epic’s Nexus is one. Health Gorilla is another. Kno2 is another.

QHINs onboard participants and commercialize access, similar to telecom carriers. The challenge is vetting customers appropriately. Once a node is on the network, the system largely trusts that it’s acting appropriately.

At scale, however, patterns emerge. Some nodes query large volumes of data but never contribute new clinical information. That raises questions about whether they’re actually providing care.

If Epic brought this lawsuit, it likely believes it has strong evidence. At sufficient scale, misuse becomes visible.

Brendan Keeler (10:47)Yes and no.

Originally, EHRs were the only on-ramps. Over time, non-EHR connectors were allowed to simplify access and expand adoption—similar to how Stripe simplified card networks.

This massively expanded the ecosystem to vendors that lacked the expertise to build CDA or XDS integrations themselves.

The business incentives differ. EHRs sell software to providers; network access is a feature. On-ramps sell access itself. Their revenue levers are value-added services, better APIs or UI, price competition, and—critically—who they sell to.

Competitive pressure leads to boundary-pushing. If one on-ramp sells to a questionable use case, others feel pressure to follow. That’s not moral failure; it’s capitalism.

That history explains the tension between EHRs and on-ramps.

As for the “smoking gun”: a complaint must survive a motion to dismiss. Epic cites traffic spikes, relationship webs, and low-value returned data. That may not be conclusive proof, but it’s enough to reach discovery. The goal is to obtain indisputable evidence and demonstrate that this isn’t hypothetical abuse.

Pryce (16:22)EHRs weren’t built to monetize data; they were built to document care. But data became valuable. On-ramps then arrived to add value—similar to how Google Flights disintermediated airlines.

The network shifted from universal trust to skepticism. Privacy concerns are real, but business incentives also matter. The solution isn’t to shut everything down; it’s responsible expansion so trust remains intact.

Brendan Keeler (17:52)Another perspective is that these networks were designed to replace fax-based transitions of care—not to be general data collaboratives.

There’s massive unmet demand: payer workflows, quality measurement, patient-directed sharing, life insurance, litigation. People look at existing infrastructure and try to repurpose it.

Providers originally agreed to participate only because rules limited use to treatment. That trust is now under strain.

Meeting this un…

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With Brad in Mexico, it was left to Pryce and I to “chop it up” and discuss the recent comings and goings of the industry and our regulatory overlords. We kept it nice and tight (at least in terms of topic sprawl, if not length) to the biggies:

* The implications of HTI 5

* OpenAI’s ChatGPT for Health

Together, we take stock of how HTI-5 tightens the screws on information access while simultaneously stripping away outdated certification scaffolding and whether the newest tech giant patient-driven aggregation can finally escape the PHR tar pit.

Health API Guy is a reader-supported publication. To receive daily content with unfiltered and slightly uncaged memes and takes, consider becoming a paid subscriber.

Relevant Articles

* Indiana Jones and the Personal Health Record

* July Monthly Review: OpenAI Builds a PHR?

* HTI-5: When the Scorpion Learns to Swim

* The End of the Standalone PHR

Chapters

* 00:00 - Podcast Naming and Introduction

* 02:56 - Understanding HTI-5 and Its Implications

* 08:51- Deregulation and EHR Evolution

* 15:04 - Information Blocking and Its Challenges

* 21:00 - Future of Health IT and API Integration

* 24:51 - The Future of Healthcare Regulation

* 25:51 - Understanding FHIR and Event Notifications

* 29:14 - The Developer Experience in Healthcare Data

* 31:16 - The Role of EHRs in Healthcare Integration

* 32:16 - OpenAI’s Recent Healthcare Innovations

* 36:12 - The Implications of ChatGPT in Healthcare

* 40:21 - Data Privacy and Security Concerns

* 45:31 - The Architecture of ChatGPT for Health

* 49:10 - OpenAI’s Competitive Landscape in Healthcare

Transcript

Brendan Keeler (00:01): All right, Not A Podcast is back. We need to really think about a name or something here.

Pryce (00:06): I know. I just Googled “Not A Podcast” or “The Not Pod” And there’s a thousand of them that are called that. So if we do start a podcast, we have to come up with a real name.

Brendan Keeler (00:16): Yeah, for any of the audience, you got good ideas, puns, we’re open for business and we’ll give you credit. But yeah, it’s you and I, we’re in January, Brad is in Mexico, we were with him drinking tequila, but we’re not, we’re instead working. And so, what are you working on? What are you thinking about?

Pryce (00:33): I’ve got tequila, but...let’s think. So very exciting week, you know, over the holidays, obviously we had HTI-5 which I want to touch on. Although it almost feels like old news now. and then this week I had, I was just deep, deep in, ⁓ like client systems documentation, which was really fun, but the, the things that kind of pulled me back to the surface of reality were the announcement about OpenAI for Healthcare and ChatGPT for Health and you’ll have to tell me what they released and how they’re different products. Yeah, I even like got on Reddit to read what people were saying about it and then I realized “Maybe that’s a bad idea” because you have like all these emotions but you don’t have anywhere to put them in Reddit. It’s just a bad idea. So we have a lot to talk about.

Brendan Keeler (01:24): I’m always surprised when I go to Reddit and I’m like, man, there’s a lot of Luddite behavior here. It was like, on Reddit in particular, we can go down that rabbit hole, it was a lot of negative, extreme negative reactions on the several threads I saw of “Why would you ever do this?” “This is a terrible idea.” Not what I expected. Yeah, yeah, not what I expected.

Pryce (01:41): You’re talking about chat GPT. Like, yeah, yeah, yeah.

The things that I have to say about it are almost exclusively, I’m tempering expectation. It’s not that exciting yet. And here’s why. And it, they don’t have to be HIPAA compliant and here’s why. And you know, so I have like maybe “detractor” things to say about it, but it’s going to be an incredible tool. We should get into that, but maybe before we get there, because then I think we’ll just go down rabbit holes forever. I would love to hear from you. You’ve written articles about it. You’re already onto almost HTI-6 in your mind, but I want to hear your take on HTI-5. Give me the heavy hitting points. What is the ASCP thinking about writing into. regulation, (as this is this is a proposed rule, so it’s not actually regulation yet)? And how does that affect the industry? Give me your take.

Brendan Keeler (02:31): We can’t let that slip that busy December slip by. so HTI-5 the fifth of the heirs of the Cures Act, right? We had the Cures Act in 2016. 2020 - they finalized the ONC Cures Rule. And then as we got past that era the certification criteria in the Cures Rule, information blocking, and TEFCA ASTP, they’re like, “Hmm. We gotta cook some things up.” Under Micky Tripathi, they did HTI-1, iterating, adding more certification criteria and changing some things in the program. And then proposed HTI-2, which was “Let’s balloon this thing up to 11. Let’s expand it to payers and public health. Let’s add tons of criteria and revise tons of criteria. And that got proposed in August of 2024 and...You know, the Democrats did not win that election. With the change of administration, they said, “Okay, let’s push out some of the things. the HTI-2 final rule was just an information blocking exception, the TEFCA, exception. HTI-3 was a Protecting Care Access exception.

And then we get to the new admin. All right, what are we going to do? Trump’s in power. As we get through the summer, we actually saw HTI-4 again, another heir of HTI-2 proposed rule that said, “Okay, actually, the prior auth criteria, the electronic prior auth stuff? That’s pretty important to the goals of the CMS because they’ve already regulated it on the payer side. So we’re going to do that piece as part of the IPPS.”

Pryce (04:03): CMS 0057 is saying, “Hey, payers, have to make APIs available that help us with prior authorization.” And then the complement to that on the provider side was HTI-4.

Brendan Keeler (04:14): Yep. And so was in the summer. They just went straight to final. They’re like, “All right, it was in the HTI-2. You guys commented. There it is. Da Vinci and NCPDP for medical prior auth and medication prior auth.” Then tick tock, tick tock, we get to December. There’s this rumor of HTI-5 and the rumors are basically “Wow, this is a deregulatory regime, right? Like Trump’s EO Trump’s executive order said deregulate all the things, DOGE was deregulating all the things.” And so finally that impetus spread to ASTP. And so that’s HTI-5, yeah. And so they deregulated, it is a deregulatory rule. So it’s pulling things out. And so know that there’s three prongs. One is deregulating the criteria, get rid of the many criteria, because some of them are old. Part two.

Pryce (04:46) Which just to be clear, we’re going to run back here in history from your historical timeline. The criteria were first created by the ACA is what created Meaningful Use which created the ASTP or ONC HITECH and then created criteria. So now we’re going almost back like 10 years ago and we’re saying, “Okay, these were important 10 years ago and ripping some of them out, right?

Brendan Keeler (05:30): Yeah, and that’s the thing is like there’s actually our goals back then were “Let’s increase adoption of electronic health records because they’re on paper.” and people can say, “That was a terrible Well, it accelerated the the digitization of that industry. So like you can say, “Should it be digital or not?” Like you’d probably say yes, if you want to do certain things like AI now, but it made the EHRs powerful, which people resent and don’t like. And so.

Brendan Keeler (05:56): Many of these criteria are old and have been revised incrementally over time and that there’s new criteria added. But yeah, it starts back then. And they said, let’s rip out anything that’s like workflow oriented, right? Like the things that say “Software vendors, thou shall have a screen that does X.” Anything of that variety? They said, let’s get rid of it by and large where it’s not some of the stuff’s in statute, it’s in the law. And so they have to have criteria that kind …

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We had fun with our “Not-a-Podcast” last week, so Pryce, Brad Thorson, and I hopped back on a video chat to try to make sense of what felt like an entire month of health IT news compressed into a single pre-holiday week. We discussed:

* ASTP’s secret new beta website that Pryce found

* Steve Posnack’s post on TEFCA and CMS Aligned Networks, and what “floor vs. ceiling” means for nationwide exchange

* Why appointment and encounter data are harder than they look, especially as exchange shifts from historical records to forward-looking signals

* Pull-based exchange vs. event-driven workflows, and where today’s networks still fall short

* Information blocking guidance from ASTP, including RPA, the manner exception, and enforcement signals

* TEFCA Operations and reciprocity, and why incremental adoption may beat premature mandates

* AT Protocol’s parallels to healthcare data exchange

* Epic’s Community Registries, and the broader implications for registry vendors and network effects

* Where HTI-5 might land, and what it signals about API-first regulation and reduced switching costs

Unscripted? Yes. A little nerdy? Also yes. Unexpected tangents and rabbit holes? Okay, yes, yet again. But we do think and hope you’ll enjoy.

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Chapters

* 00:00 - Introduction to Health Information Exchange (HIE) Dynamics

* 01:00 - TEFCA and CMS Aligned Networks: A Deep Dive

* 03:15 - Encounter Data and Its Implications

* 06:03 - The Role of Appointment Data in Healthcare

* 09:04 - Provider Steering: Opportunities and Challenges

* 11:52 - Tensions Between TEFCA and CMS-Aligned Networks

* 15:06 - Information Blocking and Regulatory Updates

* 18:01 - Recent Developments in TEFCA and ASDP

* 24:48 - Data Harvesting and Governance in Health Tech

* 26:14 - The Future of Health IT Standards

* 30:50 - Understanding HDI 5 and Its Implications

* 34:40 - The Role of Data Portability and Switching Costs

* 39:57 - The AT Protocol and Its Impact on Data Sharing

* 44:02 - Epic’s Community Registries and Privacy Initiatives

Transcript

We ran the transcript through Gemini 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 in some places.

Pryce Ancona All right, we are back to “Not-a-Podcast.” We’re back just talking over video, and we have Brad with us this time. All three of us are with HTD Health. I’m very excited to be chatting today because it’s been a busy week in DC. Just this morning, I was preparing for a little talk on how disparate HIEs and Health Information Exchange look nowadays, and I accidentally stumbled upon a beta website—a new website facade for the ASTP. With how much I’ve been anticipating HTI-5, it’s just nice that we keep getting little Christmas gifts before Christmas is actually here.

So there’s a lot to cover. We’ve got two blogs from Steve Posnack in the last few weeks. One of them is a little more directed at how TEFCA and CMS Aligned Networks are engaging with each other. I’m curious to hear from Brendan, if I may. What was your take? I know you wrote a little bit about that. Let’s dive right into it.

Brendan Keeler You may have found the beta website, but there was a whole lot of alpha in Steve’s post, if I have to go there. Steve has three posts, actually. Two weeks ago, he kicked it off saying, “I’m going to start writing again.” Then he had the TEFCA post, “The Tide and the Speedboats,” earlier this week. And then even today, another mini post saying, “Hey, check out this cool stuff we’re doing.”

Like you said, we all thought from Dr. Keane’s comments in DC last week that HTI-5 is coming. ASTP is doing something. Maybe we still get HTI-5, but we get these posts first. Earlier this week, we had “The Tide and the Speedboats,” which was a statement about TEFCA, the future of TEFCA, and the intersection and overlap of CMS Aligned Networks (another government network initiative) as part of the CMS Health Tech Ecosystem.

Steve’s statement was pretty clear. He said, “Look, these are complementary. TEFCA is the floor. CMS Aligned Networks is the ceiling, exploring the far edges, the outer reach, the really cool advanced stuff.”

The piece that I thought was interesting? He said, “Hey, scheduling data? Not something TEFCA really does right now. Encounter? Not really something TEFCA does right now.” And that’s kind of true, kind of not. Encounters are in USCDI. You can pull them. But then you can say it’s about push notifications, which is true—TEFCA doesn’t facilitate that today. I don’t know if you guys have any thoughts sparked by that or other pieces.

Pryce Ancona Brad, you go first.

Brad Thorson Well, I haven’t read Steve’s post today, so it sounds like I have some reading to do right after this. Regarding the CMS Aligned Networks: staying on the Herculean task of getting co-opetition without the regulatory framework that TEFCA has is tough. If CMS Aligned Networks starts to pull in more types of care delivery information that isn’t traditional EHI, that feels like it complicates the end goals. Pryce, I don’t know if you read it and want to say anything there.

Pryce Ancona The one thing I was going to say is, Brendan, when you called out that TEFCA does already support the exchange of encounter information, the way I read Steve’s post was actually, “Oh, we don’t have a concept for this proactive FHIR notification, FHIR subscription, or event-triggered push of encounter or appointment information.” That’s the way I read it because that’s item 15 in the CMS Aligned Network framework.

But then upon reading your thoughts, I wondered: Is he talking about clinical information from encounters, or is he talking about appointment information that you’d be receiving before an encounter takes place?

You mentioned that TEFCA is trying to create a floor and the CMS Aligned Networks are trying to create a ceiling. But I keep wondering, doesn’t TEFCA have a ceiling too, already set with the SOPs? What happens when two CMS Aligned Networks or two CMS-engaged parties in this ecosystem try to use TEFCA rails for something that TEFCA has not yet permitted or proposed? Will those things start to come to a confluence? Are they not really complementary, or will they just fall right into how people start using TEFCA? These are things that I haven’t really mulled through yet, but I have a feeling you have.

Brendan Keeler I’ve got the tea, I’ve got the holiday wine—whatever kind of mulled drink you’re looking for.

To the first point about encounter data: Yeah, if you read it as notifications, TEFCA doesn’t do that, right? There have been attempts to do notifications—Carequality, Commonwell, and TEFCA are all query-based networks. In the Carequality world, there was an implementation guide for notifications. They put it out there, said, “Here’s how we’ll do it,” and nobody used it. So, TEFCA doesn’t have that SOP or definitions in place. Fair.

But the way he wrote it implies this other criteria. It gets to a very interesting topic. As we think about the USCDI core clinical data, we have historic data—the things that have happened: procedures, medications, notes, labs. That’s “easy mode.” “Hard mode” is when we’re thinking ahead about the care plan and what needs to be done.

Unfulfilled needs are market signals. As you put a market signal onto a network, one, they’ll use it for care, understanding the care plan, and collaborating. That’s the cool part. The part that’s going to bring more tension is that it is also market opportunity. That is unrealized revenue. If I can see it, I can say, “Let me steer that towards me.”

We’ve seen that tension boil over before. SureScripts has fill data and understands there are refills outstanding. If you’re a pharmacy and you know that, you can say, “Hey Brendan, come fill it over here for cheaper or faster.” For years, SureScripts prevented pharmacies from accessing med history. They caught P…

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In this emergency video meeting (we won’t call it a podcast), Pryce Ancona and I discuss the recent antitrust lawsuit against Epic by the state of Texas (detailed in “Don’t Mess With Texas: Epic Edition”). We explore the implications of the lawsuit, the political context surrounding it, and the emotional reactions from the public and industry insiders. We have all the good stuff:

* Market definitions

* Motivations for the anti-non-compete movement

* The strategic choice of venue for the case

* Ken Paxton

We also lightly got into antitrust laws with information blocking regulations as an alternate policy tool for pro-competitive outcomes.

Health API Guy is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.

Chapters

* 00:00 - Emergency Podcast: Epic’s Lawsuit Overview

* 03:04 - Antitrust Allegations Against Epic: A Deep Dive

* 05:58 - Market Definitions and Legal Strategies

* 09:00 - The Role of Public Opinion and Political Context

* 11:55 - Implications of Venue Choice in Texas

* 15:08 - Technical Arguments and Judicial Efficiency

* 25:23 - The Challenges of EHR Competition

* 26:20 - The Complexity of Electronic Health Records

* 27:41 - Market Dynamics and Competition in Healthcare

* 30:14 Antitrust Issues in Systems of Record

* 32:42 - Information Blocking as a Competitive Tool

* 35:49 - The Role of Non-Competes in Healthcare

* 39:31 - Political Motivations and Industry Dynamics

* 43:49 - Legal Precedents and Future Implications

Transcript

We ran the transcript through Gemini 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 in some places.

Brendan Keeler (00:01) All right, Pryce, we’re here. We’ve never done this before. This is sort of an emergency—I won’t call it a podcast since we don’t have one yet—but with the stunning news that came out today or yesterday about the lawsuit against Epic by the state of Texas, led by your home state, I felt we needed something visual. It’s dropping right as we’re waiting for HTI-5, which is still pending.

Pryce Ancona (00:33) I’ve been Googling the ASTP every 10 minutes hoping there will be something new, but it’s all just articles written by you about HTI-5.

Brendan Keeler (00:44) It’s like that meme where the guy is poking it with a stick saying, “Come on, do something.” Dr. Keane promised it this week. But instead, we get this lawsuit. You’re boots on the ground in Texas—what’s the take?

Pryce Ancona (00:47) Well, I can confidently tell you that nobody in Texas knows. Nobody cares except the Health Tech Nerds, you, and I. I feel particularly divided between my former employer and my current home state. Though, living in a state doesn’t mean you have to agree with everything your state government or attorney general does.

I’m excited to dive in through the lens of politics, litigation, and technology. Each provides a different answer regarding why this is happening and what it will affect. But overall, it’s just regular Christmas time here in San Antonio.

Brendan Keeler (01:49) What jumped out at you? What was the first thing where you thought? I have many takes but I’m curious, from your educated perspective, what was most exciting or curious? I don’t know if you’ve read the whole thing front to back like I did to my daughter last night.

Pryce Ancona (02:00) I thought my one-year-old might enjoy it, but we stuck to the Christmas books instead.

For me, anytime Epic is blamed in a big antitrust or monopoly manner, I always feel that, yes, they are the biggest electronic health record, and they’re easy to gang up on. Just like when the Patriots or the Chiefs are winning everything, it’s easy for the whole NFL to hate them regardless of whether they’re cheating.

At the end of the day, Epic is a software system. If their revenue is $6 billion a year, they’re in the Fortune 500, but not the Fortune 100. It doesn’t feel like the right place to attack if you’re trying to solve the problem of healthcare costs. It is probably the right place to attack if you’re trying to set precedents in healthcare information exchange.

But I think this has a more pointed plan than just information blocking or monopolies. It’s about specific topics and political movements. That gets me angry because I feel like, “Don’t pick on the nerds in Wisconsin.” Honestly, 9,990 of the 10,000 are just trying to do their best. Some might be more cunning, but generally, they are good people.

Brendan Keeler (03:46) It’s interesting because you’re gravitating towards these emotional topics. The things we intuit when we think about antitrust and monopoly are often: “How does it feel as a person interacting with that company?” But the reality is, market dominance isn’t about that. Market distortion is about that. Antitrust, as a tool, is meant to stop market distortions in the face of market dominance.

Taking a step back for those who haven’t seen the news: Ken Paxton and the state of Texas have accused Epic of antitrust violations. This is a more direct form of antitrust regarding the markets they define than the two private antitrust cases we’ve seen, like Particle v. Epic. Those were interesting because the markets they claimed—payer platforms and managed care software—were adjacencies involving “leveraging” market dominance in one area to shake ground in another.

Here, we have cleaner market definitions. They define:

* EHR database software for acute health systems.

* EHR database software for academic medical systems.

* EHR applications.

They claim Epic has a monopoly in the first two, and through tying and bundling, is monopolizing the third. At face value, that is a stronger, more straightforward path than the other cases regarding market definition. Market definition is the most critical first step for every antitrust case.

Pryce Ancona (05:38) Right.

Brendan Keeler (05:57) It is the barrier each case faces in the motion to dismiss. You can have a monopoly in a market—80% or 90% dominance—which is called a “natural monopoly.” That’s okay, so long as you’re not acting anti-competitively. Likewise, you can act anti-competitively, but if you don’t have market dominance, it’s not antitrust. If you have 10% market share, you can do all the things alleged in this complaint—like preclude access to APIs or charge exorbitant fees—but without market dominance, you cannot distort the market.

Pryce Ancona (06:29) And if they’re not breaking other laws, like being certified health IT or information blocking, then it stands.

Given the laid-out markets, what’s your take? Do you feel like those three markets are distinct? You mentioned that in your article. Unless you’re talking about a “headless EHR,” which is a tiny fraction of healthcare software, I don’t really understand this take on a “database system” versus an “application suite.”

Brendan Keeler (07:15) You’re right to hone in on that. There are a number of challenges Epic will likely rebut.

The first is commercial reality. As you define markets, they need to be tied to commercial realities. It’s glaring to people who have worked at Epic or in the industry that the buyer is the health system. They aren’t buying an “EHR database” separately. Very rarely do you see an EHR where you swap in PostgreSQL versus the next thing. As we shift toward the cloud and SaaS platforms, it’s yoked together. In the Athena world, for example, you don’t choose which database is under the hood. So, that nomenclature is off-putting and could affect the case—maybe it’s fatal, or maybe it just forces them to amend their complaint.

The second thing regarding market definition is the categorization: EHR databases for academics, EHR databases for acute, and the apps. You’d traditionally expect one core monopolized market and then the tied market. Reading the tea leaves, you sense weaknesses in the two core markets. In the acute market, do they have dominant market share? Usually, you need 70% or 80%. Epic might have 50% o…

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