The Information Exchange: Lumon on Steroids

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

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

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

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

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

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

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

Relevant Articles

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

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

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

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

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

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

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

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

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

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

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

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

Chapters

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

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

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

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

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

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

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

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

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

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

Transcript

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

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

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

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

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

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

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

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

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

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

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

Pryce (01:49): Meaner, yeah.

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

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

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

Ryan Tucker (03:53): Yeah, I do wish she followed up a little bit more, like held her a little more to the fire, but also she’s at the Epic conference. I wouldn’t be able to do that personally. There’s also like definitely some analogy to be drawn there about Lumon internally, the Innies versus the outside world. You might 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.