The Information Exchange: Nuggets and Teasers in DC

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 cliniciansRelevant 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.TranscriptWe 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. Basic office visits might eventually be done by talking to an LLM.[16:36] Brendan Keeler: The scary part is the “bell curve”. With telemedicine, we saw issues like the Cerebral case. Now with AI doctors—infinitely replicable, zero marginal cost—one bad actor scaling quickly could do quite a bit of harm.[17:59] Brad Thorson: I have a “ticking time bomb” concern that some of these access patterns—like getting Viagra on a website—discourage patients from engaging in necessary preventative care. However, these tools also allow for low-acuity care to quickly get patients life-saving medication, like HIV prevention. My “galaxy brain” jump back to ASTP is that national provider directories and data prevalence can help patients navigate to the right provider at the right time.[20:59] Brendan Keeler: You landed the plane. We have to think about whether the good outweighs the harm. The Utah pilot is well done because it’s tightly guarded and bounded with clear escalation to real providers. You have to support the government in this pursuit—to learn from the ground in a fast, iterative fashion.[22:08] Ryan Tucker: I agree. We’re comfortable with AI reducing friction for administrative workflows, but I hesitate to see a bot taking over the actual sitting down with a provider.[23:02] Brendan Keeler: Well put. We’re coming up on our 30 minutes. We’re about to see court cases from Henry Schein and Vyne. Also, the comment period for HTI-5 is closing, so get your comments in on USCDI V7, the AI RFI, and the Diagnostic Imaging RFI. We’re going to see some cool action ahead on the regulatory front. 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