
physician, programmer, and would-be pâtissier/poet. Chief Scientist at @AledadeACO and Architect for @SMARTHealthIT. Bsky: https://xitter.cf/t.co/gZapxtia3H
Madison
Joined June 2012
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To show what that looks like for imaging, I spent <24h designing a small protocol extension to make SMART Health Links stream massive DICOM studies and building an end-to-end demo.
Josh Mandel, MD retweeted
Assorted things I've been mulling over regarding agents in the economy:
• Companies are in some sense the original superintelligence. It's often the case that they can use their amortized cognitive surplus to advance their interests against those of certain consumers: relative to the optimization capacity of companies, consumers can be inattentive, underinformed, irrational, etc. (Think, say, of some of the classic insurance upsells at the end of a booking process, which is typically priced substantially above what a regular policy would cost.) Herbert Simon introduced the idea of bounded rationality, and firms often end up benefiting from it. Thanks to personal agents, we will probably get somewhat more rational in how we engage with companies.
• How exactly will outcomes change? Well, certain kinds of price discrimination will work less well (how do coupons work if every agent hunts fastidiously for them?), and certain kinds of customer cross-subsidy will change (today, people who forget to cancel subscriptions subsidize those who don't). Taken across the economy as a whole, I'm not sure what the incidence of all of this will be.
• In corporate strategy, people have long debated the relative importance of distribution and product quality. Perhaps you've made something better, but does anyone know about it? Won't people just continue to buy the ACME Corp Mousetraps? Personal agents will, I think, act as a kind of structural subsidy for product quality. How would markets look different if individuals always spent at least 10 hours researching their purchases? On the margin, focusing on making a product better is, I think, going to become a more effective strategy for companies. This is good!
• It true, a corollary is that information about product quality will become more important and impactful. Today, most people have very limited ability to aggregate and integrate such data, but agents will have insatiable thirst for such signals. (It's often said that data is becoming more valuable because it helps in the training of models. That's obviously true, but I think there's a secondary way in which it's more valuable simply as a complement to cheaper intelligence.)
• A big question is whether agents will increase superstar effects (rational agents all settle on the same product) or increase dispersion (because everyone has slightly different tastes and preferences, which agents are good at eliciting, finally overcoming the artificial clustering we've been subjected to).
• Many internet companies have monetized demand routing, which is in turn often predicated on short attention spans. "I'll click on the first thing I see." This has led to some amount of inefficiency, as companies try to propitiate capricious ranking algorithms and incur various placement fees. It's not all deadweight loss (willingness to pay is itself a kind of signal, which is valuable to buyers), but it's not great. How will the nature and value of this routing change in a world of personal agents? I don't know the answer, but I think that the effects might be pretty big.
• Much of what I'm writing hinges on the assumption that personal agents will be on the consumer's side. I suspect that that will be the winning strategy, but whether it's true, and what it means to be true, involves a lot of other questions.
Taken as a whole, the market is a massively parallelized, decentralized, and highly imperfect value attribution machine, and, taking stock of all of the effects, it seems to me that the quality point may well be the biggest: that agents will change the nature of the backpropagation such that the rewards for better products increase. Maybe this is too optimistic, but I suspect (and hope) that companies that make things that they're proud of will feel that the universe is a little more partisan in their favor.
I love the problem definition and sketch of the solution space here. In some sense the "dumb network" footprint is what both TEFCA and CMS Health Tech Ecosystem are moving towards (networks facilitating trust and routing, but smart edge nodes that can talk directly to each other). I'm curious if you think this is likely to succeed in (re)shaping networks, or if not, why not?
Replying to @healthapiguy
(inspired by a @chrissyfarr tweet, a convo with @franjohn21, and the work of the always great @JoshCMandel)
Made using freely available FHIR APIs from open.epic.com.
Yes, the best frontier agents right now output undecipherable language and it's annoying -- but a compensatory corollary: they will happily accept your own made-up language as input, where you obliquely refer to design ideas, architectural components and goals with the laziest linguistics gestures.
Some contexts are just cursed? Reading through the thick Claudish: "The last one is the most useful failure: the model can be set and the card still refuses, so the gate isn't the value — it's a dirty flag only the real picker sets." Bottom line; model returns to say "I failed" instead of solving the problem (in the same way we've already established will work, like, 10 times by now).
So, out of the box Android migration is... decent. But you lose settings for lots of apps, and you lose all non-Play-store apps. But with wireless ADB and Claude code coordinating, I got *everything* reconfigured. Including my growing pile of vibecoded apps + my open source podcast db.
Can y'all please settle on a direction of travel for usage progress bars @OpenAI and @AnthropicAI?
"/goal [briefly described exit condition]" is basically asking the genie to grant your wish... with all the, uh, provisos, and quid pro quos Disney warned about.
As you know, ONC can require any triggers it wants whenever/ifever they mandate support for the patient data feed. Historically when an IG defined multiple optional capabilities, ONC has designated their own set of mandatory ones to align with their priorities. Reconciliation with the published IG can happen (much) later or never. So I don't see lack of Argo-mandated triggers as a fundamental flaw. (Remember this spec came out of HTI-2 proposals that were themselves quite vague on use cases -- so instead of trying to pick winners or downselect data types, we described a general purpose approach that covers any uscdi patient oriented data. This should allow what you describe as "enrollment" to the extent that it is supported by uscdi -- and if it is not supported by uscdi then there is more fundamental work needed before onc can try to solve the problem.)
Replying to @healthapiguy
The fix is small: require the feed to fire on the resources that actually signal enrollment (Patient, Encounter, ServiceRequest, MedicationRequest, Appointment), and a whole swath of provider apps could finally run on FHIR alone. A glorious future awaits.
"The federal contracting demimonde may feel odd to the uninitiated civilian eye (including me), but is ultimately a fixture of the GovCon firmament."
Some harnesses seem to actively penalize thorough reading (i.e. agent tries to read a file; harness is like "here's 50 lines, if you reeeally want more, you can make another read call".)
Replying to @MatthewBerman
I noticed that, its usually a result of the agents being "lazy" and not reading their .md files or reviewing the entire codebase. In hunt for faster responses they cause this kind of caos
Totally agree it's about "how easily you can let it go." This is why I don't use agent frameworks and rewrite (re-prompt) infra I think I might need over and over again for ~every project. (Seriously: keeps infra light and keeps me grounded in what I actually need vs can jettison).
Everyone is writing about agent loops right now. Including us at Cursor, because they're so powerful. But here's a prediction: a year from now, nobody will be talking about them.
Not because they weren't useful. Because they'll work right out of the box. Batteries included. No instructions necessary.
Feels a lot like prompt engineering two years ago. It was incredibly important. People wrote courses on it. Now you just talk to your agent like a normal person.
That's the strange thing about AI right now. You learn something critical, get huge gains, and before long it's the new normal and something else is the bottleneck. So the alpha isn't what you know. It's how fast you learn it, and how easily you can let it go.
Josh Mandel, MD retweeted
You don’t need to be a cardiologist to see it – it’s obvious… ex post
But we’ve been looking at ECGs for predictors of sudden death for 100 years
No one saw it until the AI pointed it out!
I am *constantly* typing some variation of "the output should be self contained and not make references to our conversation here -- the reader will not have this conversation in context"
Replying to @emollick
Its a consistent theory-of-mind failure in models that are otherwise suprisingly good at theory-of-mind












