Interoperability as Infrastructure: Policy, Prior Authorization, and the Path Forward with ONC
In this episode of The Dish on Health IT, Tony Schueth is joined by Dr. Thomas Keane, National Coordinator for Health IT at ONC, along with Alix Goss and Janice Reese. The conversation moves between policy, standards, and real-world implementation, with Tony often grounding the discussion in the practical friction points the industry continues to face.
Tony opens by noting that “ONC is ONC again,” setting a lighter tone while also framing the broader conversation around where federal health IT policy is headed. He highlights Dr. Keane’s unusual background spanning engineering, clinical practice, and federal leadership, asking how that path shaped his perspective on impact.
Dr. Keane explains that his transition into policy was driven by exposure and opportunity, but importantly, he continues to practice medicine. Tony picks up on that point, noting how rare it is for a National Coordinator to still be actively practicing, reinforcing the value of having a policy leader grounded in real-world care delivery.
Interoperability at the “Speed of Trust”
Tony then shifts the conversation to one of his core themes: interoperability as infrastructure. He references Dr. Keane’s framing of interoperability needing to operate at the “speed of trust,” and pushes on the tension between that vision and the reality of legacy systems still dominating the market.
Dr. Keane responds by walking through ONC’s dual-track approach. On one hand, rulemaking like HTI-5 is pushing toward a FHIR-based, API-driven future. On the other, ONC recognizes that legacy standards are deeply embedded and must continue to be supported. He also points to the CMS Health Tech Ecosystem initiative as a powerful example of how government can accelerate progress by convening stakeholders rather than relying solely on regulation.
Tony brings Janice Reese into the discussion to ground this vision in implementation reality. Janice emphasizes that the biggest barriers are not the APIs themselves, but the underlying trust infrastructure. She outlines identity, security, consent, and directory services as the key gaps preventing interoperability from scaling nationally.
Imaging as a Case Study in Misaligned Incentives
Tony pivots to diagnostic imaging, framing it as a clear example where standards exist but adoption lags. He references the continued reliance on physical media like CDs and asks whether the issue is less about technology and more about incentives and certification.
Dr. Keane agrees and shares a detailed example from his time as a radiologist, describing how consolidating imaging workflows improved efficiency and reduced turnaround times. He uses this to illustrate the broader point: the technology exists, but economic and operational incentives often work against seamless data exchange. He also notes that ONC’s recent RFI is intended to better understand these barriers and inform future rulemaking.
Tony keeps the tone light with a quick aside about McDonald’s and queue efficiency, but uses it to reinforce a serious point. Even when better systems exist, organizations sometimes stick with less efficient models because they are familiar or expected.
Prior Authorization: Progress, but Still Fragmented
Tony then moves into prior authorization, referencing CMS-0057 and Da Vinci use cases as signs of progress, particularly on the medical side. He contrasts that with the ongoing fragmentation in pharmacy prior authorization and asks how ONC is thinking about bridging that gap.
Dr. Keane emphasizes that standards alone are not enough. Real progress depends on making those standards usable in practice. He points to ongoing work with EHR vendors, PBMs, and intermediaries to ensure that real-time prescription benefit tools deliver complete and accurate information that clinicians can trust.
Tony and Alix build on this by connecting real-time benefit checks to broader price transparency efforts, suggesting that combining these capabilities could fundamentally change how patients and providers make decisions together at the point of care.
Price Transparency: Still Not Patient-Friendly
Tony directly challenges the current state of price transparency, asking how the industry moves beyond “check-the-box” compliance to delivering something that is actually usable for patients.
Dr. Keane acknowledges that while progress has been made, much of the data remains too complex and not sufficiently tailored to individual patients. He notes that CMS continues to iterate on requirements, but that making cost information actionable at the point of care remains an ongoing challenge.
AI: From Hype to Real Utility
Tony transitions to AI with a callback to a joke Dr. Keane made about AI either transforming healthcare or reducing it to three bullet points. He uses that setup to ask whether AI can realistically make complex healthcare data usable for patients and clinicians.
Dr. Keane answers with a firm yes, pointing to existing use cases in radiology and clinical workflows where AI is already improving accuracy and efficiency. He shares examples of AI identifying stroke patterns, highlighting abnormalities in imaging, and even summarizing clinical reports.
Tony then brings the conversation back to risk, asking about overreliance on AI and how policy should address bias and accountability. Dr. Keane is clear that responsibility still sits with the clinician, noting that physicians are trained to recognize bias and must independently validate AI-driven insights.
Janice and Alix add that AI’s success ultimately depends on the quality and standardization of the underlying data. Without consistent, trusted data, AI will simply amplify existing gaps.
Information Blocking and Enforcement
Tony closes the main discussion by turning to information blocking, asking what message ONC has for organizations that continue to restrict data access under the guise of technical or legal constraints.
Dr. Keane outlines a range of enforcement mechanisms, from corrective action plans to potential financial penalties. He emphasizes that while ONC prefers to work with organizations to resolve issues, the expectation is clear: data must flow.
Final Call to Action: Data Liquidity
As always, Tony ends with a call-to-action question. If there were one thing the industry could do starting tomorrow, what would it be?
Dr. Keane’s answer is direct: make data liquid. He ties this back to reducing administrative burden, improving price transparency, and enabling better patient decision-making. The goal is a system where data flows seamlessly, at the direction of the patient, to support care and operations.
Janice and Alix close by reinforcing that the industry does not lack standards or policy direction. The real challenge is aligning stakeholders and scaling adoption.
The episode closes, as always, with the reminder that Health IT is a dish best served hot.
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