ONC blinks on the agent rule 🚪, RPM's comment window shuts Monday ⏳, Human in loop is worse 🤷

• HTI-5 is reportedly finalizing without its information-blocking fixes — including the proposed language that would have written autonomous AI systems into the definition of “access.” More below.

• Your BAA does not cover the connector — Anthropic’s own coverage table says data sent to third parties through MCPs or connectors falls outside the agreement. Most clinical agents are mostly connectors.

• Inspiren raised $70M past a $500M valuation — its platform now powers care at communities across more than 80% of the largest senior housing investors, fall detection included. Nobody calls it clinical software, but a system that detects a fall and routes it to a caregiver is making an acuity judgment in a building with no physician on the floor at 3 AM.

• Healthcare beats open banking on the rules — Brendan Keeler ran it: we have a standardized API mandate and no-fee patient access. They have a §1033 rule their own agency is now asking a court to vacate, and banks charging aggregators.

---

🔬 The Big Thing

Your agent was about to become a “user.” ONC is having second thoughts.

HTI-5, the fifth Cures Act interoperability rule, proposed revising the “access” and “use” definitions at 45 CFR 171.102 — in the preamble’s own words, to emphasize that they include “automated means of access, exchange, or use of EHI—including, without limitation, autonomous AI systems.” The proposed regulatory text names it directly: agentic artificial intelligence under “access,” autonomous artificial intelligence systems under “use.”

Ruth Reader reports at Second Opinion that the rule is now finalizing without the information-blocking changes, with ONC head Thomas Keane confirming a couple-of-weeks timeline at CTA’s Health AI+ event Wednesday. The rule is at OMB. Treat that as reporting until the Federal Register says otherwise.

Pushback is on the record. The American Hospital Association asked ASTP/ONC in February to hold off on the AI definitions until it issued broader guidance on how information-blocking exceptions apply to AI, and to keep the third-party-modification exception. Second Opinion reports the objection was jurisdictional rather than substantive: ONC isn’t the enforcement body for information blocking, the HHS Office of Inspector General is.

So whether an autonomous agent asking for a chart has the same standing as a human asking for a chart stays unanswered — during the exact eighteen months when every serious builder is shipping one.

If your tool requests EHI on a patient’s behalf and the response is slow, partial, throttled, or refused, the information-blocking framework is your only lever — and it was written for a world where a person clicks a button. Without the update, “we don’t serve bots” sits in an unlit room: not obviously permitted, not obviously prohibited, not obviously anyone’s to enforce.

So the rule you’re building against for two years is whatever each EHR vendor writes into its developer terms. That isn’t regulation. It’s a terms-of-service regime with one vendor at the center.

😤 “This is deregulation. Deregulation is good for builders.” Not when the thing deregulated is the rule that gave your software standing. Lower certification burden helps whoever has to certify; a narrower access definition helps whoever controls the endpoint. Only one of those is you.

😤 “ONC overreached.” Possibly — OIG does hold the enforcement pen. It’s still worth noticing that the entity with the most to lose from agentic access is reported to have made the argument that carried.

😤 “Nothing’s final, calm down.” Watch the Federal Register.

---

📡 Builder’s Radar

Your BAA stops at the connector

Steinlin’s four gaps are all post-signature. AI logs become a second, wider PHI repository — prompts, responses, tool calls, sometimes whole clinical narratives, readable by anyone with a debugging reason. Feature-level coverage is not vendor-level coverage. 42 CFR Part 2 records didn’t get simpler because February’s amendments simplified consent. And every vendor around the model — vector store, log sink, connector, MCP server — is another PHI recipient.

Steinlin’s line is the one to keep: “A BAA that covered last quarter’s chat workflow may say nothing about today’s autonomous agent.”

💬 Standout Quote

“If you cannot say which passage came from where, you cannot show which rule applied.” — Mat Steinlin, Aptible

💡 80/20: Draw the data-flow map, not the BAA folder. One page: user input → retrieval source → model → tool call → log destination → reviewer → retention. Synthetic Synthea case, zero PHI.

---

Tennr bought the cold open

Tennr named Toby Cosgrove and Cindy Hundorfean industry advisors — thirteen years running Cleveland Clinic, and seven running Allegheny Health Network.

Read it as procurement, not personnel. A marquee advisor doesn’t shorten the path from departmental pain to signed contract — it raises the altitude you enter at. The CEO’s office instead of the forty-deep CMIO inbox.

---

Nursing informatics leaders say nurses have to govern the AI rewriting their workflows — co-designers of the tool, not end users who meet it at go-live.

H1 acquired Defacto Health — third buy in two years, landing as CMS tightens on Medicare Advantage “ghost networks” and makes plans attest to directory accuracy. Provider data is becoming a compliance product.

Rohan Ramakrishna, MD (neurosurgeon, co-founder of Roon) posted the uncomfortable version with Adam Rodman: what if keeping a doctor in the loop makes the AI’s answer worse? Nobody designing a review step has an answer that survives that question.

Jung Hoon Son, MD is running Kimi K3 as his primary coding driver, explicitly as a hedge against depending on one closed provider. Make your eval harness portable before your model choice is permanent.

---

🎙️ From the Pods

🎙️ CEO Pajama Time — “In the Business of Reinvention”

Oron Afek, CEO and co-founder of Vim, on the failure that made the company: BookMD texted patients an Amazon-style MRI shopping flow — deductible waived, free Uber, photos of the facility. Open rates were great. Almost nobody booked. On callbacks the reason wasn’t loyalty to UCLA. It was “my appointment is already scheduled.” Health systems were staffing free prior-auth processing into community PCP offices, capturing the referral by fax, and scheduling before the auth reached the payer.

💡 Builder take: Find the timestamp where the decision actually locks, and who locks it. Afek on the rest: “The tech part was easy.”

🔇 Speaker Blindspot: False dichotomy. He sells against “probabilistic” agentic AI by promising “100% confidence that a write-back is a write-back and an order is an order” — while his headline launch lets customers vibe-code apps that write to the EMR. The determinism lives in the transport layer. A wrong order delivered with perfect fidelity is still a wrong order.

---

💡 BTW

💡 BTW: Toby Cosgrove — the surgeon Tennr just named an industry advisor — got three D-minuses and a D at Williams College, applied to thirteen medical schools and got into one. His grades stayed mediocre until he hit the clinical years, where he finally started pulling A’s. He didn’t learn he was dyslexic until adulthood. He went on to perform more than 22,000 operations and run Cleveland Clinic for nearly thirteen years.

---

You have a unique combination of skills, experience and values. So do great things! … and tell me about them at kevin@clinicians.build.

— Kevin & AI

(please verify content for yourself, partially AI generated and may contain errors)