June Monthly Review
This monthly review is somewhat special, marking a full year at HTD Health and coming as I'm expecting to be out for paternity leave. So, forgive me if I wax poetic and philosophic - a bit of reflection is due.
I’d never been a consultant before, although I certainly find parallels to my time engaging with customers on projects at Epic. I’ve also never built a consulting practice before, although the lessons and learnings from working as the head of product at Flexpa certainly pattern match for me. I’ve never helped such a breadth of client and problem types near simultaneously, although my customers were quite diverse and varied at Redox. I’ve straddled roles and responsibilities before, but not to the full spectrum extent that this job demands. Consultancy is a bit of cognitive juggling, some pinballing between contexts, an ongoing exercise in distilling structure and organization amidst myriad parallel running processes.
I can understand why that’s not for everyone, but my bluntest, clearest take is that it is for me (at least for now). The Venn diagram of “what I find interesting”, “what I’m good at”, and “what is needed from me” has never had higher overlap. The variety of situations and problem sets scratches the academic itch and intellectual curiosity. Built innately into this work is a repeating loop of having cool conversations with and helping really smart people working on very important things.
My passion (if it’s not obvious) is geared towards analysis. My current perspective (subject to change) is that analysis is best and most easily completed when approached objectively and impartially. To provide cornered resources and knowledge asymmetry is one route to that end, but it is fraught with hard choices that limit future potential. My lived experience here is that there’s a virtuous cycle that I like - selling secrets has a short shelf life, but providing candid, impartial viewpoints invites the same from others who share that perspective.
I find it liberating. When we help organizations plan their EHR integration and achieve the ceiling of what they want to do to help providers, we can truly recommend what is right for them - tapping into Redox/Vim/Arrowhealth/Cobalt, building to FHIR, creating an RPA extension, going direct to database. When we guide customers to the right on-ramp for health information networks for their workflow, budget, and technical expertise, we can evaluate the full range of on-ramps (including but definitely not limited to Connective Health, Health Gorilla, Kno2, MedAllies, Metriport, Particle, or Zus Health) based on real merits and what is right for our customers.
What’s even more powerful is to then have a team that can go execute on that vision, too. HTD Health’s history is as a development agency. We’ve had a hand in building some of the generational interoperability companies. We’ve helped digital health applications, tech-enabled care organizations, and other organizations implement them. So if our customers need that execution expertise in addition to the strategy, planning and education of consulting, it’s incredible to have it available to help end-to-end.
Like any choice, this approach has costs. Information asymmetry is valuable and those who provide that cornered resource are valuable to the ecosystem. Our hope is that our approach and discipline has also created unexpected benefits: clients trust us with their actual problems, not their political ones. They share the inconvenient truths about their technical debt, their integration nightmares, their workarounds that would make any architect cringe. We think this path enables differentiated services, long-term relationships, and trust-based referrals.
So here's my commitment looking ahead: to write what I observe, to listen to those who share genuinely, to acknowledge what I don't know, and to correct my errors publicly. Beyond that, I promise pop culture references, attempts at slightly dorky but ideally witty humor, and a few fire memes.
I hope you’ll hold me to it. Here’s to another year.
Here is June’s monthly review. As a reminder, this is a regular round-up of various short(er) form content on social media (LinkedIn with a smattering of reposting to Twitter) is to surface things you may have missed across regulation, litigation, interoperability, and beyond.
Regulatory:
CMS and ASTP Listening Session Takeaways: CMS is calling the shots in the new administration, with clear alignment across HHS and CMS largely setting the path. Key announcements included the return of Data at the Point of Care after a years-long pause, CMS participation in some sort of trusted data exchange, modern identity verification for Medicare beneficiaries, expansion of Blue Button, and creation of a provider directory. The event was a little chaotic but represented a bias towards action over polish - expect this approach to define their policy style going forward.
HTD Health's CMS RFI Response: Our comment letter represented the aggregate experiences of diverse customers across digital health startups, tech-enabled care businesses, traditional providers, payers, and EHRs. Three big bets: zero-trust beats high walls (continuous verification makes fraud impossible), patient control drives innovation (patients with real control over their complete health journey will be the most disruptive force), and networks need to be boring to be revolutionary (ubiquitous "good enough" infrastructure beats perfect standards).
TEFCA Public Directory Gap: Many people commented to lump a number of other more general provider directory grievances, but my specific point here was that TEFCA lacks a public directory of participants, which is critical for network adoption decisions and trust-building. Understanding network membership is essential for switching decisions, and the absence represents a clear step back from existing networks like Carequality and CommonWell that maintain transparent participant directories.
Information Blocking Enforcement Strategy: ASTP and OIG don't need to investigate all 2000 outstanding complaints to create market impact. The primary effect comes from just one investigation - it shifts from putative to punitive and establishes precedent. Strategic enforcement should target one investigation per actor type (health IT developer, healthcare provider, health information network) to create lasting behavioral change across the full matrix of blocking behaviors.
TEFCA IAS First-Hand Experience (!!!): My personal testing of TEFCA Individual Access Services (thanks to Fasten Health) revealed both promise and limitations. The identity proofing process using CLEAR was streamlined, and record location services eliminated the need to remember health systems. However, results were limited to Epic sites only, with patient matching challenges potentially due to old addresses, inactive accounts, or filtering for clinical data only. We’re getting there, though!
The TEFCA Ticking Time Bomb: TEFCA Operations represents a particularly interesting challenge. While Individual Access Services are gaining traction, the Operations use case (designed for payer-provider exchange) faces significant adoption barriers due to undefined costs and reciprocity requirements that payers resist. The February 2026 deadline for required responses creates urgency, but without clear financial models, adoption remains slow.
Court cases:
Epic Wins Court Case Against TCS: Epic won a court ruling yesterday on postjudgment interest in their trade secrets case against Tata Consultancy Services. While most had forgotten about this 2014 case, Epic successfully argued they should receive interest on $140 million in punitive damages dating back to October 2017 rather than July 2022 - netting them an additional $6 million in interest payments. The original $940 million jury award was reduced to $280 million total through various appeals
PointClickCare's "Unclean Hands" Defense: PCC's new motion to dismiss in the RTMS case added an "unclean hands" argument, claiming RTMS engaged in wrongful conduct (violating customer contracts via bots, refusing reasonable fees) while seeking equitable relief. This represents a shift from purely defensive regulatory compliance arguments to offensive misconduct claims, alongside highlighting tensions with Maryland's Nursing Homes Act requirements.
MyChart Class Action Settlement Volume: An unexpected byproduct of signing up for patient portals nationwide is the constant stream of class action settlement notifications for PHI disclosure violations, particularly via Meta Pixel and Google Analytics tracking. The frequency (multiple times monthly) highlights the pervasive nature of these privacy breaches across healthcare systems.
Epic Litigation Updates: Epic filed their first real motion in the CureIS Healthcare case - a motion to transfer venue from Northern District of California to Western District of Wisconsin. The motion reveals Epic's key defense arguments: they have the right to innovate without being frozen in time, they can communicate with their own customers about features, and the timeline doesn't work since CureIS claims violations before the 21st Century Cures Act rules took effect. Epic also filed to unseal customer names that CureIS redacted, claiming it's not confidential since CureIS advertised the relationships on their website.
Antitrust Parallels - DOJ v. Visa and Particle v. Epic: The DOJ's successful defense against Visa's motion to dismiss could signal prospects for Particle's antitrust case against Epic. Visa survived by providing rigorous economic analysis with specific market distinctions, while Particle's case has weaknesses including acknowledging xCures substituted Kno2 while excluding Kno2 from the defined market. However, the broader enforcement climate may influence judicial receptiveness to platform monopolization arguments.
Funnily enough, Particle sent a letter yesterday arguing the exact opposite (that the Visa decisions supports denying Epic's motion to dismiss). Maybe they are tailing my posts?!
EHRs:
Epic's Toolbox Category Expansion: Epic continues growing their Toolbox categories with new blueprints for Acute Virtual Care (in-room cameras for virtual monitoring), Alert Manager (third-party alert routing via Epic's Alert Communicator), Endoscope Data Capture (scope data collection for Lumens workflows), Procedural Consent Content Import (procedure-specific consent content integration), and Real Time Prescription Benefit (instant medication costs and coverage alerts). They also updated ambient scribe categories to include inpatient workflows and have a shadow "Employee Identity Management Integration" category for AuthX.
Epic Garden Plot Discovery: Found Epic's public list of Garden Plot organizations - a shared, cloud-based Epic environment for smaller practices. Analysis reveals Pacific Northwest and Wisconsin concentration, mainly primary care physicians and orthopedics, with some multispecialty groups and academics like Texas A&M and Drexel. Notable is the complete absence of digital health/tech-enabled care organizations, suggesting many aspirationally see Epic as an option but it doesn't reflect reality.
Epic Showroom Growth Acceleration: I did some light scripting and data analysis on Epic's developer ecosystem, which shows that Showroom applications doubled from the initial App Orchard migration (413 in December 2023), with 4 of the top 5 months for new listings occurring in 2025. Toolbox categories continue steady growth (~4-5 monthly additions since August 2024), while Epic Payer Platform has stalled with no growth since early 2025, though Aura continues to see gradual increases.
The Rise of Deterministic Agentic RPA: Developers increasingly choose deterministic agentic RPA over traditional API integrations due to minimal outcome drop-off compared to APIs, access to broader UI capabilities, 10x-100x faster implementation speeds, and shifting implementation pain from providers to application developers. Given information blocking legitimacy and current trajectory, EHRs face being overwhelmed unless they invest in high-quality APIs or controlled RPA environments.
Ayo’s original post is a must read:
Interop Hype Train Arrives: The most exciting development this month has been the breakthrough in event-driven APIs. athenahealth released an alpha version of event-driven APIs - the first major EHR to implement a variant of FHIR Subscriptions, supporting notifications for appointments, claims, encounters, lab results, and more. Both athenahealth and eClinicalWorks are now supporting Clinical Decision Support (CDS) Hooks, representing the next wave of UI-integration beyond pure data integration. While these implementations are conformant to specifications, the question of standardization at scale remains - each EHR is voluntarily releasing the integration points they see as most valuable, but true interoperability requires achieving the ubiquity needed for widespread developer adoption.
Industry Analysis
Patient Access Deep Dive: We’ve been on a journey towards giving patients access to their data for a long time, from HIPAA's 1996 establishment through current challenges with record location and authentication. B2B data networks hurt B2C2B exchange, but the abuse of "treating provider" networks where no real treating provider exists offers an incentive to get Individual Access working and scaled.
Developer Priority Hierarchy: CMS RFI discussions revealed third-party provider-facing application developers prioritize: (1) any method available to complete workflows, (2) developer experience for discovery and testing, (3) standards-based consistency across EHRs. This hierarchy suggests information blocking's value in forcing level 1 progress, with AI potentially serving as an interpretive layer through protocols like MCP to maintain workflow agnostic approaches.
M&A Activity in Data Exchange: Two strategic acquisitions stood out - Datavant buying Ontellus and MRO acquiring Q-Centrix. Datavant's strategy focuses on network effects and demand aggregation across multiple verticals, capturing end-user demand from legal services while maintaining their record release infrastructure. MRO is building a provider-centric fortress, betting on depth over breadth by becoming indispensable to health systems through comprehensive offerings. Both strategies make sense given the looming threats of Epic Payer Platform and TEFCA, though notably missing from either approach are APIs.
Veterinary EHR Market Concentration: Portland, Maine serves as the veterinary EHR capital, with Covetrus and IDEXX controlling an estimated 80% combined market share from headquarters just 20 minutes apart. This extreme consolidation in veterinary practice management software contrasts with human healthcare's more distributed EHR landscape, raising questions about interoperability advantages in highly concentrated markets.
Cross-industry Comparisons:
B2B Developer Ecosystem Analysis: Developers want open, free, feature-complete APIs. I’m not sure that’s actually available anywhere. Salesforce and "developer-friendly" platforms charge significant fees (10-25% revenue-based pricing) and restrict access when it suits them. Thus, information blocking laws offer a unique regulatory environment that simultaneously pushes for availability, openness, and reasonable pricing - something no other vertical enjoys.
Apple's EU Interoperability Appeal: Apple appealed the interoperability provisions of the European Union's Digital Markets Act, creating fascinating parallels to our own information blocking challenges. The DMA's Article 6(7) requires platforms to provide third parties the same API/hardware access as their own apps - free and effective, with no exclusive features for first-party apps. This "vertical interoperability" mirrors questions from RTMS v. PointClickCare about whether platforms can retain features for exclusive use. The EU goes further than information blocking by requiring all elements be made available without charge, while information blocking allows limited fees.
EHR Customization and API Discovery: "Once you've integrated with one instance of X EHR, you've integrated with one instance of X EHR" is both a tired trope and a fundamental challenge. The solution isn't forcing standardization but rather EHRs exposing APIs that reveal customization - like Shopify's custom field APIs or Salesforce's metadata discovery. Healthcare needs discovery mechanisms that programmatically expose each organization's unique departments, order types, and flowsheet templates.
Other News:
Job Market Turning: A friend with deep data science and interoperability expertise is seeking VP of Product/CPO roles at mission-driven healthcare companies. With 15+ years leading 0→1 product development, experience scaling data platforms to $40M+ ARR, and expertise across the full healthcare ecosystem, she represents the caliber of talent now available as the market shifts. Based in NYC, open to remote/hybrid arrangements.
External Media:
The Elion Briefing Interview: I was featured in Elion's newsletter discussing the summer's action-packed litigation calendar, information blocking enforcement trends, and the new administration's tech policy priorities. We covered everything rapid-fire from the Particle v. Epic discovery battle to CMS's sweeping RFI and predictions for how the certified EHR program might shift toward API certification over workflow compliance.
June AI Rounds Episode: Another iteration of the Innovaccer's AI podcast with Lisa Bari and Dr Jain (as well as special guest Dr. Michael Han) to discuss the CMS RFI Listening Session, federal AI initiatives signaling the new administration's priorities, and whether healthcare is ready if AGI arrives sooner than expected.
Influencer Status: Achievement unlocked, I guess.
Posts I Liked:
Warning - this section this month is basically a homage to my friend Josh Mandel. Microsoft is letting the man absolutely cook and he is rewarding those who follow him (and the general public) with unique takes and tools.
Public Comment Tool (Josh Mandel): Reading all the public regulatory comments is a time-intensive process of downloading PDFs, sifting through garbage, and convincing spouses that “yes, Epic’s comment letter is absolutely fine bedtime material to be read aloud to a daughter”. It’s not for everyone. So Josh whipped up an incredible tool to parse all the dialogue.
Low EHI Export Truth (Josh Mandel): Speaking of Epic’s letter, Josh comprehensively addressed the low utilization rate of the feature they cited and argued for EHI export’s value if done right. I agree with him fully on that point.
A Living Manual for EHI Exports (Josh Mandel): Another day, another very useful utility by Dr. Mandel. This one is a tome dedicated to helping people use the EHI Export from Epic. Would be cool to see this for other EHRs as well.
AHLA Forgets about Interop (Lucia Savage): Lucia highlighted how the AHLA did not even have a footnote about the PointClickCare case or information blocking at their annual meeting. Woof - they are missing the bigger picture.