Physician context is the moat 🩺, AI-native EHRs ditch the seat 💳, Anthem loses the NSA rematch ⚖️

The 15 minutes a physician spends on HPI, PMH, and ROS before touching a patient is the same discipline that separates usable agentic code from disaster — and almost no one with that training has noti

The clinical history IS the prompt. A physician just said it out loud.

Adam Carewe, MD posted an essay yesterday titled “The Vibe Coding Gap Is Not a Coding Problem”. His core move: line up the clinical history (chief complaint, HPI, PMH, social history, ROS) against the production vibe-coding discipline Anthropic’s Eric describes — “spend 15 to 20 minutes collecting context before writing a single prompt. Explore the system. Build the plan. Name the constraints. Then let the model execute.” The two disciplines are the same discipline. The physician has been running it since internship.

His closing line deserves to be pinned above every clinician-builder’s desk: “System B required us to outsource building to engineers because they held the only skill that could produce software. System C makes domain knowledge the scarce resource and code the commodity.”

This is the thesis of this newsletter in someone else’s handwriting. It’s also a clinical informaticist who saw patients this week saying it cleanly — not a founder deck, not a LinkedIn think piece. When a physician builds the argument, the argument is built. The only thing left to do is build the thing.

😤 Haters

“This is just the same ‘doctors should code’ talk we’ve had for ten years — dressed up in vibe-coding lingo.” Partially fair. The rhetoric isn’t new. What’s new is the economics. Ten years ago, a physician who learned React had bought themselves a six-month path to a mediocre prototype. In 2026, that same physician, armed with the clinical history reflex, can be in a working agentic prototype by Sunday night. The new part isn’t the encouragement; it’s that the cost structure finally matches the encouragement.

“Most doctors I know can’t actually model a software system — they can model a patient.” Correct, but you’ve conceded the point. Modeling a patient IS modeling a system — the inputs are messy, unreliable, adversarial. The output is life-changing. The feedback loop is 48 to 72 hours. If you can disposition a complex polypharmacy patient with an occult sepsis workup, you already have the cognitive substrate for “this tool returns 200 but silently drops the field.” The translation is smaller than it looks.

“The physicians ACTUALLY building are a rounding error — stop pretending they’re a wave.” Also fair. Fewer than 1% of practicing US physicians have a repo they’ve committed to in the last year. But a wave doesn’t need 50%. It needs maybe 2%. When 30,000 of the 1.1M clinicians in the US start shipping specialty-specific tools on agentic stacks, the market looks nothing like it did. We are not there yet. We are also not far.

💡 80/20: The skill your residency drilled into you — do not order the CT without the full history — is now directly monetizable in a market that didn’t know it needed it. Try: write your next LLM-backed tool the way you write an H&P. Chief complaint (one sentence: what does this tool do?). HPI (user story, onset, quality, aggravating/relieving factors). PMH (systems it touches — EHR, scheduler, lab). Social (who uses this and on which shift). ROS (ten-system review of what else could break). Then — and only then — open the editor.

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📡 Builder’s Radar

Vertical EHRs are about to get un-seated.
Sam Toole’s two-part series argues that specialty EHRs (think ModMed, NextGen, AdvancedMD) sit on a pile of clinical context and charge per seat — a pricing model that dramatically underprices what the software is positioned to deliver. AI-native entrants can ship better software at lower prices and add consumption-based revenue streams the incumbents can’t match. The PE thesis behind Thoma Bravo-NextGen, Warburg-ModMed, and Francisco Partners-AdvancedMD assumes sticky seat-based contracts. That thesis has a new expiration date.

😤 Haters

“Nobody is actually ripping out their ophthalmology or derm EHR this year — switching costs are brutal.” True, and that’s exactly what makes the window long and the outcome slow-motion obvious. The PE lockup periods outlive the buyer’s confidence. The installed base doesn’t need to switch this quarter; it needs to hear about a cheaper, better-at-documentation competitor and stop paying list price at renewal.

“Consumption pricing in clinical software has been tried and doesn’t work — providers hate variable cost.” Fair in 2019. In 2026 providers have already accepted scribe pricing per encounter, coder AI priced per chart, and prior-auth bots priced per submission. The variable-cost muscle is built. The seat model is the anomaly now, not the default.

💡 80/20: If you’re a physician owner-operator in a fragmented specialty, you are the ideal first customer of an AI-native vertical EHR — and probably also the ideal founder of one. Reframe: the PE-owned incumbent isn’t a competitor, it’s your TAM. Start by auditing what yours bills for per seat vs what it actually does per encounter.

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Anthem’s attempt to relitigate its IDR losses got thrown out.
On April 9, Magistrate Judge Karen Scott (C.D. Cal.) dismissed Anthem’s federal RICO, ERISA, and fraud claims against HaloMD and co-defendants — the billing company that helps providers navigate the No Surprises Act Independent Dispute Resolution process. Anthem argued HaloMD flooded IDR with ineligible disputes labeled as eligible. Judge Scott ruled NSA only permits federal review under narrow circumstances (corruption, bribery, destroyed evidence) and that the IDR process already lets participants flag ineligible disputes to the arbitrator. Adopting Anthem’s position, she wrote, would subject “nearly every eligibility determination” to federal court review. Anthem will appeal to the Ninth Circuit. Three parallel BCBS suits remain active in Texas, Georgia, Ohio.

😤 Haters

“This is a minor procedural ruling — insurers will just find another angle.” Partially. But the phrase “procedural ruling” is doing a lot of work. The federal claims — the ones with treble damages and nationwide preemption potential — are gone. What remains is state-law claims that can be refiled in CA state court, where insurers have much less leverage. The fee-structure argument (”arbitrators have bad incentives”) also got explicitly rejected on merits, which is not a procedural loss.

“Builders don’t care about an NSA case.” Builders who touch out-of-network billing care a lot. If you’re shipping anything that routes claims, drafts appeals, or helps providers survive the IDR flood, the legal substrate you’re building on just got considerably firmer. The ruling doesn’t create the opportunity — it protects the existing one.

💡 80/20: If your product touches the IDR process — appeal drafting, QPA calculation, dispute filing — read the ruling itself, not the summary. The judge’s framing of what “bad faith” looks like under NSA will shape vendor contracts for the next 24 months. Try: run your own product’s IDR filings against Scott’s corruption/bribery/destroyed-evidence bar. If your software couldn’t survive that bar on its worst day, harden it now.

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Behavioral health visits passed primary care in 2024. Nobody is talking about it.
CDC Data Brief 558 on sources of usual care — re-surfaced this weekend in Jared Dashevsky, MD’s “Where Americans Get Care in 2026” — landed a stat worth stopping on: 66.4 million behavioral health visits vs 62.8 million primary care visits in 2024. For the first time. 90% of adults still say they have a usual source of care, but the age split is stark — 12.2% of 18-34 year olds name urgent care or a grocery-store clinic as their usual source; only 4% of 65+ do. 80% of practicing physicians now work for hospital systems or corporate entities (2023 data). Urgent care centers nearly tripled since 2010 while PCP density dropped 22%.

😤 Haters

“Urgent care replacing PCP isn’t news — everyone has been predicting this since 2015.” Predictions aren’t data. The stat that flipped is data. The moment behavioral health visits exceeded primary care visits is the moment “primary care” stopped being the default front door of American medicine. If you’re building on assumptions from 2019, that assumption is now wrong.

“Agentic AI to ‘expand PCP panel capacity’ is the Dashevsky pitch and it’s basically marketing for his favored vendor.” Somewhat. He’s transparent about which product he’s bullish on. But the diagnosis (supply won’t move; AI panel expansion is the near-term lever) is correct independent of whose tool wins. The bottleneck isn’t model quality — it’s continuity, documentation, and the longitudinal relationship, which urgent care structurally cannot provide.

💡 80/20: The real building opportunity isn’t “replace the PCP”; it’s “be the longitudinal layer that makes urgent care visits count.” Every 18-34 year old who walks into a CVS MinuteClinic is producing a data event that currently disappears into a silo. Try: spend a weekend mapping what it would take to stitch one urgent-care visit into a longitudinal record that a PCP could act on later. That’s the build.

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OpenAI shipped a frontier reasoning model for biology. You weren’t on the invite list.
OpenAI introduced GPT-Rosalind — its first frontier reasoning model purpose-built for the life sciences. Deployed under trusted-access terms to Moderna, Amgen, the Allen Institute, and Thermo Fisher. This is a peer story to Anthropic’s Project Glasswing / Mythos cyber-research model — both labs are now shipping narrowed-access frontier models to strategic partners in regulated domains, weeks apart.

😤 Haters

“’Trusted access’ is paperwork. Same model, fancier paperwork.” Partially true — the weights are the weights. But the paperwork is the point. Moderna and Amgen are getting a model-use arrangement that small clinical AI startups cannot match, and the regulatory comfort is real: shared liability, audit trails, indemnification. If you’re a small shop trying to sell bio reasoning into enterprise pharma, the bar just moved.

“There’s no way a bench scientist at Moderna is going to trust LLM reasoning on a drug target over a PhD chemist.” Not today. The observable effect over the next year is not replacement; it’s asymmetry — teams with GPT-Rosalind triage faster, read more papers, propose broader mechanism hypotheses. A group that’s 30% faster at literature-to-hypothesis doesn’t “replace” anyone. It just leaves the teams without it behind in 18 months.

💡 80/20: For clinician-builders outside of big pharma, the read is about tiers of access, not the model itself. Frontier labs are now shipping regulated-domain models with restricted rollouts. Reframe: “frontier model access” is becoming a commercial asset, not a commodity, in biotech/health. Plan for a world where your local-first MedGemma pipeline is the open substrate and the frontier-model calls are a per-query premium paid only when warranted.

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🛠️ From the Workbench

isitagentready.com — see if your site speaks agent.
Cloudflare launched a public scoring tool that audits your website for agent compatibility: robots.txt posture, sitemap, MCP discoverability, Agent Skills, OAuth, access control. Drop in a URL, get a score and an actionable fix list. Paired with Radar data showing current web-wide adoption is low. Useful as a fast audit when you’re about to stand up something agent-facing.

⚠️ Verify: This is an uptime/config audit, not a security audit. A high Agent Readiness Score says nothing about whether your app correctly handles deep-merge updates, hallucinated success responses, or prompt-injection through fetched content. Run it for the hygiene layer — do not treat the score as an endorsement.

😤 Haters

“Why do I care about my clinic site being ‘agent ready’? Patients aren’t using agents yet.” Some aren’t. Many are — just not the way you think. Copilot, Perplexity, ChatGPT search, and agentic browsers already fetch doctor pages when patients ask “what should I expect at my derm appointment.” If those fetches return garbage, your office gets skipped. The cost of fixing it (robots.txt, a sitemap, an MCP endpoint for hours/location) is hours, not weeks.

“Cloudflare is grading its own homework — of course every site needs their products.” Partly true. But the open-ended checks (sitemap, robots, a clean API endpoint, OAuth done right) don’t require Cloudflare. They just require you to not be hostile to crawlers that don’t have a 2015 UX.

💡 80/20: Treat agent-readiness the way you treated HIPAA awareness in 2015 — not glamorous, but the building block everything else sits on. Try: run isitagentready.com on your own clinic or product site today. Fix the top 2 items before your next deploy.

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🧰 Builder’s Tip

Weekend Project — Build an LLM tool-call safety wrapper (3-4 hours).

This weekend’s build is inspired by Orqisai’s “three hardest problems” post — the three production failure modes that bit every builder who shipped an agent against a real API: (1) LLMs silently PUT partial payloads and wipe your fields; (2) LLMs report “success” on 404s; (3) query params arrive as strings instead of dicts and the request just quietly returns nothing.

The weekend project: write a minimal safe_call(tool_fn, args) wrapper in Python (or TypeScript) that does three things — fetch current state and deep-merge before any write, prefix every non-2xx response with the literal string Error:, and coerce string-shaped query-param inputs into dicts with a logged warning. Point it at a FHIR sandbox (Medplum, Inferno, or the HAPI public server) and run 10 test cases where your agent “updates a Patient resource” while only mentioning the one field it wants to change. Confirm the other fields survive. Starter test: ask the agent to update Patient.gender and verify Patient.birthDate is still there afterward.

You end Sunday with a wrapper you can drop into every subsequent agent project and not re-learn these three lessons the expensive way.

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What are you building this week? Reply and tell me — I read every one.

— Kevin