Healthcare is Hard: A Podcast for Insiders

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May 2026

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Healthcare is Hard: A Podcast for Insiders views healthcare transformation through the lens of prominent leaders across the industry. Through intimate one-on-one discussions with executives, policy advisors, and other “insiders,” each episode dives deep into the pressing challenges that come with changing how we care for people. Hear the unique perspectives of these industry leaders to get a better understanding of what is happening today, the challenges across the healthcare ecosystem, and how innovation is really shaping the future of healthcare delivery.

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May 28, 2026Episode 9039 min

Why Healthcare Leadership Is Harder Than Ever: Cedars-Sinai’s Tom Priselac on Culture, Change and Cost

Cedars-Sinai has evolved from a community hospital to a major academic health system with an international reputation for quality care, community service, research and education. Much of that evolution and expansion took place under the leadership of Tom Priselac, who served as President and CEO for 30 years, until his retirement in 2024.After joining Cedars-Sinai in 1979, Priselac spent nearly half a century at the organization, rising through a series of leadership roles as the institution expanded its academic mission, built an integrated medical network and adapted to major shifts in healthcare delivery. That long tenure gave him a rare vantage point on how health systems change over time, and what it takes to lead through multiple eras of disruption.In this episode of Healthcare is Hard, Priselac reflects on why the leadership job in healthcare feels more challenging now than ever. The pace of change is faster, and today’s leaders are navigating a far more complicated environment shaped by financial pressures, regulatory demands, rapid technological advancement and major scientific breakthroughs. But even with all that complexity, Priselac argues that the fundamentals of leadership remain the same. He advocates for creating a culture of excellence, helping people understand why change is necessary, and making sure an organization can absorb change in a thoughtful way. Some of the topics Tom and Keith discussed include:Culture at the heart of healthcare. Priselac returns repeatedly to the importance of values, emotional intelligence and culture in healthcare leadership. In his view, an organization’s culture reflects the decisions, behaviors and priorities of its leaders, and that matters even more in complex environments like academic medical centers. Whether the challenge is aligning faculty, community physicians, researchers or administrators, success depends on keeping patient care at the center and building a shared sense of mission.Pushing change too fast. One of Priselac’s clearest leadership lessons is that organizations and people can absorb only so much change at once. While today’s leaders face real pressure to move more quickly, he warns that some of the biggest mistakes happen when executives short-circuit the change management process. Looking back on his own career, he says some of his most important learning came from moments when he pushed for too much change too quickly.Why cost and access still keep him up at night. Even with all the promise of genomics, proteomics, cell and gene therapy, and AI, Priselac remains deeply concerned that healthcare’s affordability and access problems are worsening faster than policymakers are addressing them. He points to clear signs of strain already in the system – communities losing access to care, hospitals in urban areas operating beyond capacity, and patients spending hours waiting for admission. For all the excitement around innovation, he sees cost and access as the country’s most urgent unresolved healthcare challenges.To hear Keith and Tom discuss these topics and more, listen to this episode of Healthcare is Hard: A Podcast for Insiders.

April 16, 2026Episode 8946 min

A Giant Leap for Healthcare: Dr. Bob Wachter on AI, Clinical Workflows and the Patient-Doctor Relationship

Dr. Bob Wachter describes his career as the result of “what happens when a political science major becomes an academic physician.” Rather than focus on one specialty or scientific domain, he became fascinated by the healthcare system itself and has spent more than 40 years examining how care is organized, where it breaks down, and how technology can help make it better.The author of more than 300 articles and six books, Dr. Wachter famously coined the term “hospitalist” in 1996, helping give rise to one of the fastest-growing specialties in medicine. Among other roles, he has served as president of the Society of Hospital Medicine and chair of the American Board of Internal Medicine. He also founded and directed the Division of Hospital Medicine at the University of California, San Francisco (UCSF), where he is currently Professor and Chair of the Department of Medicine.For the past 15 years, Dr. Wachter has focused much of his attention on the impact of technology on healthcare, a topic that shaped his two most recent books. In The Digital Doctor, he explored why electronic health records created as much frustration as progress. But he has since come to see that EHRs were never the full answer, only the foundation healthcare needed before better tools could emerge. On the day ChatGPT was publicly released in 2022, Dr. Wachter recognized the major shift ahead, paving the way for his newest book, A Giant Leap.In this episode of Healthcare is Hard, Dr. Wachter joined Keith Figlioli to discuss why AI is different from previous waves of health IT, how quickly it may change care delivery, and the opportunity for AI to address many of healthcare’s long-standing problems. Some of the topics Dr. Wachter and Keith discussed include:Why “better than today” may be the right benchmark. One of Dr. Wachter’s core arguments is that AI does not need to be perfect to be valuable in healthcare. If clinicians are currently expected to review 600-page charts in minutes, keep up with a flood of new medical literature, and navigate increasingly complex administrative tasks, then tools that can summarize, suggest, and support – even imperfectly – may still represent a meaningful step forward. The real challenge will be keeping isolated failures or headline-grabbing mistakes from derailing progress that is net positive. Reshaping the patient-doctor relationship. Dr. Wachter expects patients to be increasingly informed by the ability to use AI to review records, understand symptoms, and map care decisions. However, he warns that it could create tension for clinicians that are already working within tight visit windows and may need to spend more time responding to GPT-generated advice. He also discussed how it raises bigger strategic questions for health systems, as AI-guided navigation may begin to influence where patients seek care, and even which institutions they trust. Elevating primary care. Dr. Wachter sees AI as a kind of specialist in a clinician’s pocket, opening the possibility for primary care physicians to do more by offloading routine work and improving their ability to support complex cases. He also discussed how patients will be more likely to shift away from health systems, and more towards new entrants in the market for primary and preventative care. Underestimating the speed of change. In Dr. Wachter’s view, many leaders don’t yet realize how fast AI will change healthcare. For health systems, the risk is not just missing out on productivity gains. It is losing control of the patient relationship, the referral pathway, and ultimately an organization’s competitive position. To hear Keith and Dr. Wachter discuss these topics and more, listen to this episode of Healthcare is Hard: A Podcast for Insiders.

March 19, 2026Episode 8842 min

From Pilots to Production: Boston Children’s John Brownstein on the Next Phase of AI in Healthcare

Dr. John Brownstein has been on the leading edge of digital health since medical school, where he was drawn to epidemiology because of the opportunity to use data sets for large-scale impact beyond the exam room. He’s been on a hunt for data ever since, shaping a career that has spanned public health, technology, startups, and healthcare innovation.Dr. Brownstein helped develop Google Flu Trends, served as a healthcare advisor to Uber, and launched one of the first data analytics companies in public health, where he applied AI long before it became today’s dominant topic. In 2015, he became Chief Innovation Officer at Boston Children’s Hospital, where he has helped turn it into a proving ground for emerging technologies.With its manageable size, nimble culture, and an administration willing to invest in innovation, Dr. Brownstein has helped turn Boston Children’s into an ideal setting for testing emerging technology. This environment, which put Boston Children’s on the front edge of healthcare IT for more than a decade, has positioned it to help lead the current AI wave.In this episode of Healthcare is Hard, Dr. Brownstein joined Keith Figlioli to discuss AI adoption, how it’s changing health systems, and what those changes mean for the companies selling to them. They discussed topics including:The fast pace from pilots to production. Only half joking, Dr. Brownstein mentioned that his conversation with Keith would be outdated by the time the podcast aired. The reality is, everything related to AI is moving so quick – even in healthcare, which is bucking its reputation as a slow mover on tech adoption when it comes to AI. Health systems are no longer just dabbling in isolated pilots; they’re taking significant steps toward broad deployment, using AI for intelligent automation, workflow support, and clinical tools in ways that are beginning to produce measurable impact.The build versus buy equation. After launching Boston Children’s innovation program, Dr. Brownstein recognized that having a large engineering team wasn’t sustainable and began turning to startups that could innovate and deploy quickly. But that tide is shifting again, with the ability to use AI for internal development. He hasn’t closed the door on startups, but says the bar is much higher. Companies selling into providers will need to show a stronger moat – whether through proprietary data, regulatory expertise, deep workflow integration, or some other advantage that cannot be easily recreated in-house.Designing AI architecture. AI procurement has become much more strategic than investing in point solutions. Dr. Brownstein discussed how health systems need to think about foundation models, hyperscalers, core systems like Epic, and point solutions, and how they all fit together to benefit users including clinicians, researchers, patients and families. For startups and incumbents alike, success will depend not only on product performance, but on how well a solution fits into the broader technology stack health systems are now building around AI.Why culture is just as important as capability. Even with strong interest in AI across healthcare, adoption is not purely a technical issue. Dr, Brownstein notes that while demand for AI tools is high, there are also signs of fatigue and anxiety as AI becomes an unavoidable topic in boardrooms, leadership meetings, and day-to-day work. With real questions about trust and job impact, organizations will need to pair technical progress with a thoughtful approach to culture, communication, and workforce readiness.To hear Keith Figlioli and Dr. John Brownstein discuss these topics and more, listen to this episode of Healthcare is Hard: A Podcast for Insiders.

February 19, 2026Episode 8738 min

DC’s Ambitious Plans for Modernizing Health Tech: U.S. DOGE Service Administrator & CMS Strategic Advisor, Amy Gleason

The daughter of a hospital administrator, Amy Gleason never considered a career in the public sector – she went straight into healthcare. As an emergency room nurse, she started to see the dangers that unfold when healthcare providers don’t have access to the information they need to treat patients. Those experiences drove her towards a tech career in the emerging electronic health records space before a very personal experience altered her professional path yet again.Amy’s active and healthy 10-year old daughter began suffering unusual healthcare events, from rashes and headaches to broken bones. Eventually, she couldn’t walk. It took more than a year from the start of these symptoms for doctors to diagnose her with a rare autoimmune disease. Even then, it was an accidental diagnosis from a dermatologist conducting a skin biopsy.Amy attributes the delayed diagnosis to siloed data, not unsimilar to the challenges she experienced as a nurse and was working to solve in the EHR space. It motivated her to co-found a company focused on helping patients with chronic diseases access their data to share it with the providers and family members helping to navigate complex care journeys.In 2015, Amy’s work earned her an award from the White House for Champions of Change in Precision Medicine – her first foray into the public sector. By 2018, she entered civic service full time with a role at the United States Digital Service, which she describes as “DOGE 1.0.”In this episode of Healthcare is Hard, Amy talked to Keith Figlioli about the work she’s doing now as Strategic Advisor to CMS and Administrator of the U.S. DOGE Service, where her main mission is modernizing technology across government agencies for the millions of people who rely on federal services every day. This ranges from modernizing FAFSA and the student loan process, to improving the Visa system ahead of the World Cup, and work on various critical healthcare systems. Some of the topics Amy and Keith discussed in this episode, include:Bold plans for a Digital Health Ecosystem. Launched in July 2025, CMS’ Health Tech Ecosystem is a public-private partnership designed as a voluntary, fast-moving alternative to slow rulemaking. Rather than years of regulation, the program uses pledges, working groups, and short development cycles to put interoperability building blocks and real patient-facing use cases in place. The goal is to get usable capabilities into the market in months – not years – let the community iterate, and have baseline use cases live by March 31, 2026 with more advanced capabilities rolling out by July.Carrots and sticks before regulation. Recognizing the limitations of regulation, Amy talked about a new philosophy for incentivizing the market to change behaviors on its own first. “Carrots” include the rural health transformation fund and the recently introduced ACCESS model, a 10-year pilot that, for the first time, lets tech-enabled services bill Medicare directly. “Sticks” include stricter enforcement of information-blocking rules.Replacing the 1970s-era Medicare claims system. Amy discussed plans to replace Medicare’s decades-old COBOL-based adjudication platform. While it’s a stable platform, it can’t support real-time processing, AI, or rapid change. To replace it, CMS is looking to commercial, off-the-shelf solutions that operate at scale so claims processing can be modernized, made real-time, and integrated with new interoperability rails. It’s a concrete example of bringing modern engineering and product thinking to government technology.To hear Amy and Keith discuss these topics and more, listen to this episode of Healthcare is Hard: A Podcast for Insiders.

January 15, 2026Episode 8646 min

Glimmers of Nonpartisan Progress: Decoding ACCESS, TEMPO and the Latest Government Healthcare Initiatives

After three decades working to deliver easy, fast and cost-effective patient experiences through technology, Ryan Howells is more optimistic about the future than he’s ever been before.At a time when healthcare has been at the center of polarizing and partisan politics, Ryan is focused on an area foundational to digital health that he says draws consensus across party lines: data exchange and interoperability. Freely moving data can unlock innovation in technology, payment models, and regulation to make healthcare work better for everyone, and Ryan is extremely encouraged by the openness to ideas and volume of activity he’s seeing from the second Trump Administration in these areas.As Principal at Leavitt Partners since 2015, Ryan collaborates with the private sector, the White House, Congress, HHS, and the VHA to improve health care nationwide. For the past ten years, he has also led the CARIN Alliance, a bi-partisan, multi-sector alliance uniting industry leaders to advance the adoption of consumer-directed exchange across the U.S.In January 2023, Ryan joined Keith Figlioli on the podcast to discuss the myriad of new possibilities emerging in healthcare as a result of better access to data. In this episode, he recounts the progress and obstacles since that conversation, but more importantly, helps unpack the flurry of new activity.Topics Ryan and Keith covered include:ACCESS & TEMPO. These are the latest examples of two new government programs that Ryan believes will remove barriers to innovation. ACCESS is a CMS initiative that now makes it possible for technology companies to bill Medicare directly for digital health services – and get paid only when patients achieve specific, measurable clinical outcomes. Ryan explains how ACCESS is a breakthrough for transparency and has the potential to change contracting for digital health vendors as health system may now ask to share risk. TEMPO is a program from the FDA that complements ACCESS by allowing participating companies to bypass traditional device clearance processes through “enforcement discretion,” provided they share real time data with the FDA. Ryan explains how this oversight lowers cost and complexity for startups and accelerates the path to market for new digital health solutions.Removing administrative roadblocks. In early 2025, Ryan’s team at Leavitt Partners published a paper titled, “Kill the Clipboard” that offered recommendations to cut administrative costs, lower the burden on consumers and providers, and modernize the health care data exchange ecosystem. Ryan discussed recommendations like the need for stronger enforcement of information blocking rules and suggestions for the government to change its certification program to focus on APIs, versus functionality of EHRs. He explained how these things would allow health systems to control their own data, build cloud-based workflows, and integrate with payers and innovative companies more easily.Linchpins for data liquidity. Ryan believes that achieving true data liquidity in healthcare requires three foundational elements: a cloud-based data store, an API endpoint, and robust digital identity credentials. With these in place, he says organizations can exchange data securely and efficiently, supporting everything from public health to quality measurement and pharmacy exchange. He says these are the linchpins to finally achieve the data liquidity needed for innovation, interoperability, and improved patient outcomes.To hear Ryan and Keith discuss these topics and more, listen to this episode of Healthcare is Hard: A Podcast for

December 18, 2025Episode 8535 min

340B Unpacked for the Holidays: Policy, Controversy, and Impact

Sitting at the intersection of healthcare policy, hospital finance, and patient access, the 340B drug discount program is a hot button issues in the pharmacy space. The program is critically important to providers that serve high volumes of low income and vulnerable patient populations, but it’s drawing increasing scrutiny.340B was established in 1992 as part of the Public Health Services Act to help providers stretch scarce resources, expand services, and improve access to care for those most in need. It does this by requiring pharmaceutical manufacturers participating in Medicaid to sell outpatient drugs at significant discounts to safety net hospitals and other covered entities – including federally qualified health centers (FQHCs), HIV clinics, homeless clinics and more. Covered entities are reimbursed for the full cost of the medication and use that margin to offset losses from caring for low‑income, uninsured, and underinsured patients. It’s become a critical component to their operating budgets.The program has grown substantially since its inception, with increasing numbers of hospitals and entities participating. This expansion has led to questions about whether the program is being used as intended or stretched beyond its original purpose.Ted Slafsky – one of the nation’s leading experts on 340B – joined Keith Figlioli for this episode of Healthcare is Hard to unpack this complex and critical program. For 22 years, Ted served as president and CEO of 340B Health, a Washington D.C.-based association of over 1400 hospitals nationwide participating in the 340B program. In 2020, he started 340B Report, the only news outlet in the country focused exclusively on the 340B program.Some of the topics Ted and Keith discussed include:Balancing oversight and operational efficiency. The 340B program faces growing calls for transparency and accountability, with proposals for more detailed reporting on how hospitals and clinics use the savings. While oversight is important to ensure compliance and integrity, Ted warns that excessive administrative requirements could overwhelm providers and divert resources away from patient care. The challenge is finding a balance that promotes trust without creating an operational burden.Dispelling Myths. One common misconception about 340B is that it’s a direct patient discount program. Ted addressed this myth, explaining how the discount is intended for providers to give them more resources to reach and serve more patients. The other myth Ted addressed is how the program is described – mostly by the pharmaceutical industry – as a “markup scheme.” He doesn’t think that’s a fair depiction and explained that revenue from commercially insured patients is essential for offsetting the cost of treating uninsured and underinsured patients, making the program a lifeline for safety-net providers.An uncertain future. The 340B program faces significant uncertainty as policymakers consider major changes. Recent efforts to replace upfront drug discounts with a rebate model could strain the financial stability of small and rural providers, while federal proposals to cut Medicare Part B reimbursement add further pressure. At the same time, state legislatures are enacting a patchwork of laws to protect providers and restore contract pharmacy discounts, creating complexity across the country. Ted advises providers to not simply hope for the best. He urges hospitals and health centers to engage directly with lawmakers and their staff by inviting them to visit facilities where they can see the program’s impact and its role in supporting vulnerable populations.To hear Ted and Keith discuss these topics and more, listen to this episode of Healthcare is Hard: A Podcast for Insiders.

November 20, 2025Episode 8432 min

The Big Beautiful Maze of Health Policy and Innovation

From being at the center of some of the most significant shifts in U.S. healthcare policy over the past two decades, Liz Fowler can offer valuable perspective in uncertain times. In her most recent government role, Liz served as director of the Center for Medicare and Medicaid Innovation (CMMI), an organization she helped create a decade earlier. As Chief Health Counsel at the Senate Finance Committee, Liz played a major role in the drafting and passage of the Affordable Care Act (ACA) in 2010, which established CMMI. She then served as special assistant to President Obama on health care and economic policy at the National Economic Council to implement the ACA. She also played a key role drafting the 2003 Medicare Prescription Drug, Improvement and Modernization Act (MMA).Liz says she’s a public servant at heart, but credits her time in the private sector at Johnson & Johnson and WellPoint (now Elevance) for making her a more effective government leader. Today, Liz provides guidance, insight, and strategy for a broad array of health care stakeholders, including payers, health systems and providers, trade associations, technology companies and more as co-founder and managing partner of Health Transformation Strategies.Liz talked to Keith Figlioli for this episode of Healthcare is Hard to share insight and perspective as healthcare organizations navigate changing regulations, including those in the “Big Beautiful Bill.” Topics they discussed include:The ROI of CMMI. Liz explained the difficulties tracking the savings that CMMI generates. She believes the mechanisms for measuring CMMI are too narrowly defined, making it hard to capture the full impact of its work. She advocates for a broader definition of success, emphasizing that innovation is a process—one where failure can provide just as much impact and opportunity for learning.Limited bandwidth for innovation. It’s a challenging time for healthcare organizations that are scrambling to meet deadlines and ensure they’re in compliance with various regulations, including provisions of the “Big Beautiful Bill.” Liz believes this is pulling time and attention away from innovation and slowing progress toward advancing value-based care. Despite the overall constraints Liz sees with the current regulatory environment, she’s optimistic about rural health transformation funding and how that could spark some innovation.The revolution that’s not coming. Throughout the conversation, Liz reiterated that “healthcare is hard.” She cautioned against expecting sweeping, revolutionary change, noting that progress in healthcare is incremental. Drawing on her 25+ years in health policy, Liz encouraged listeners to celebrate small victories and keep pushing forward, as real transformation happens step by step.To hear Liz and Keith discuss these topics and more, listen to this episode of Healthcare is Hard: A Podcast for Insiders.

October 16, 2025Episode 8348 min

Lessons from Public Sector Leadership: Former CMS Administrator and FDA Commissioner, Dr. Mark McClellan

Dr. Mark McClellan has served as a Member of the President’s Council of Economic Advisors, Administrator of the Centers for Medicare & Medicaid Services (CMS), and Commissioner of the U.S. Food and Drug Administration (FDA). But his experiences before, and accomplishments following these leadership roles at the highest levels of government health policy are equally important to his perspective on the healthcare ecosystem – especially during a time of rapid policy change.Dr. McClellan always intended on pursuing a medical degree and entered a joint Harvard-MIT program that took him in a slightly different direction. He ended up studying economics and the rising cost of healthcare at MIT. He ultimately earned a medical degree from the Harvard-MIT Division of Health Sciences and Technology, a Ph.D. in economics from MIT, and a master’s in public administration from Harvard’s Kennedy School.Dr. McClellan began his career at the Treasury Department in the Clinton Administration, and returned to public service under the George W. Bush Administration where he led the FDA and CMS. Today, Dr. McClellan is the Robert J. Margolis, M.D., Professor of Business, Medicine and Policy at Duke University and the founding Director of the Duke-Margolis Institute for Health Policy. His work centers on improving health care through policy and research, with a focus on payment reforms, quality, value, and biomedical innovation.With his expertise in medicine, economics and public policy, Dr. McClellan talked to Keith Figlioli in this episode of Healthcare is Hard to share his perspective on adapting to rapid change in the current healthcare landscape. Topics they discussed include:Misalignment of innovation and outcomes. While advancements in digital health are coming to market faster than ever before, Dr. McClellan says there’s still a lack of technology truly centered on keeping patients healthy. He says traditional payment methods make it hard to support this type of innovation. For example, advancements in AI are helping physicians gather information for prior authorization requests, and ambient scribing saves time with note taking and administration. But these technologies essentially help providers see more fee-for-service patients or bill for more profitable services. He argues that more outcome-oriented payments are needed to advance technology-embedded care models. The evolution of value-based care. After Congress passed the Medicare Modernization Act in 2003 to establish Medicare Advantage, Dr. McClellan became administrator of CMS at the President’s request to lead its implementation. With unique insight from leading some of the earliest VBC programs, he shared his thoughts on the speed of adoption and why it hasn’t happened faster. He discussed how early MA models needed to be based on existing fee-for-service infrastructure, his surprise that not much has changed, and his optimism that it’s finally starting to.Mobilizing private capital for public health. Private investment will be essential to support the significant changes required to improve healthcare – especially with uncertainties around future levels of government funding. Dr. McClellan explained how the Duke-Margolis Capital Impact Council (CIC) was launched to guide and improve the role of private investment in healthcare. He described how members of the council are developing and sharing practices for investors and their portfolio companies to track health value return on investment alongside financial ROI.To hear Dr. McClellan and Keith discuss these topics and more, listen to this episode of Healthcare is Hard: A Podcast for Insiders.

September 18, 2025Episode 8248 min

Emerging Technologies (Part 3): Microsoft’s Chief Architect for Health on the Saga of Interoperability and AI

Dr. Josh Mandel says his first love was software. But on a whim, while studying computer science and software engineering at MIT, he took a course that opened his eyes to the world of medicine and genetics. It changed the trajectory of his career away from software – but only temporarily. He entered medical school after earning a bachelor’s degree in computer science and began rotating through Boston-area hospitals at the same time Meaningful Use accelerated adoption of electronic health records. With a background in computer science and training as a physician, Josh understood the promise of EHRs, how medical professionals would actually use them, and how to make them better. Based on his unique combination of expertise, Josh took it upon himself to begin making improvements to the systems at the hospital where he worked.Nearly two decades later, Josh is now Chief Architect for Health at Microsoft Research. In this role, he focuses on developing an ecosystem for health apps with access to clinical and research data, leading standards development for data access, authorization, and app integration.For the third and last episode in this Healthcare is Hard series, Keith Figlioli spoke to Josh about data interoperability and emerging technologies. This conversation follows previous episodes with Epic’s head of R&D, Seth Hain in Part 1, and the Interoperability Practice Lead at HTD Health, Brendan Keeler – also known as the “Health API Guy” – in Part 2.Some of the topics Keith and Josh discussed include:The standards landscape. At Keith’s request to explain the evolution of health IT standards as if he were talking to a seven-year-old, Josh breaks it down in simple terms. He outlines how structured data related to things like allergies, medications, and vital signs are well standardized today, while newer data types like genomics and imaging remain fragmented. He also explains the role of HL7, FHIR, and the Argonaut Project in shaping interoperability.How AI flips the script on standards. Josh says generative AI changed the way he thinks about engaging with the standards community. After getting an early preview of GPT-4 a few years ago, he realized that it would dramatically reduce the value of detailed data structure standards over time. He says that as AI becomes better at interpreting unstructured data, the focus will shift from formatting to governance – who can access what, and under what conditions. He described the concept of “language first interoperability” as one initiative he’s working on where automated agents query each other in the equivalent of an email or chat thread. Instead of exposing extensive details upfront, agents that can access unstructured data and understand things like medical necessity and other guardrails can send messages to each other until they make a conclusion about a specific task. This technology will increase the value of standards for data access and privacy, while reducing the focus on interoperability.Advice for startups. In a fast-moving landscape, Josh urges startups to “build and explore.” He emphasizes the importance of staying close to customers, iterating quickly, and leveraging today’s best models while keeping an eye on what’s coming next. His advice: don’t get bogged down in yesterday’s limitations—focus on unlocking value now and adapting as the technology evolves.To hear Dr. Mandel and Keith discuss these topics and more, listen to this episode of Healthcare is Hard: A Podcast for Insiders.

August 21, 2025Episode 8149 min

Emerging Technologies (Part 2): Past, Present & Future of Healthcare Interoperability with HTD Health's Brendan Keeler

Brendan Keeler’s path into healthcare interoperability has been anything but straightforward. After early stints implementing Epic in the U.S. and Europe, he helped hundreds of startups connect to provider and payer systems at Redox, Zus Health and Flexpa before taking the reins of the Interoperability Practice at HTD Health. Along the way, his Health API Guy blog turned dense policy updates into plain-language guides, earning a following among developers, executives and regulators. In this episode, Keith Figlioli sits down with Keeler to examine the “post-Meaningful-Use” moment. They discuss how national networks like Carequality and CommonWell solved much of the provider-to-provider exchange problem, only to expose new gaps for payers, life-science firms and patients. Keeler says the real action right now is in three places where the biggest, most dramatic changes are about to happen: Antitrust pressure on dominant EHRs. Epic’s push into ERP, payer platforms and life-sciences services could trigger “leveraging” claims that force unbundling, similar to cases already moving through federal court. Information-blocking enforcement. Recent lawsuits show courts siding with smaller vendors when incumbents restrict data access, a trend Keeler believes could unwind long-standing moats around systems of record. A CMS-led shift from policy to execution. With ONC budgets flat, Keeler sees CMS using its purchasing power to unblock Medicare claims data at the point of care, expand Blue Button APIs, and accelerate work on a national provider directory, digital ID and trusted exchange frameworks. Keeler’s optimism is pragmatic. AI agents may someday chip away at entrenched EHR “data gravity,” but real progress, he says, will come from steady, bipartisan layering of HIPAA, Cures Act and TEFCA foundations. He also pushes back on venture capital’s “system-of-action” thesis. Enterprise EHRs remain sticky because switching costs—massive data migration and workflow retraining—are measured in decades, not funding cycles. AI could reduce these problems, but only slowly and only if underpinned by trusted exchange standards. Zooming out, Keeler describes a policy arc that starts with provider-to-provider exchange, widens to payer and patient access, and ultimately points toward a nationwide digital ID that could streamline consent and credentialing. For innovators, his north star is clear: build for identity-verified, standards-based exchange; assume open APIs will become table stakes; and judge success by the friction you subtract from everyday care—not by how flashy the demo is. To hear Brendan Keeler and Keith unpack these issues, listen to this episode of Healthcare is Hard: A Podcast for Insiders. Please note that this episode was recorded earlier this summer, before the CMS meeting, and that some developments have occurred since then.