Josh Mandel, MD

My Regulations dot gov comment analysis of 97 submissions on the Imaging Interop RFI is up and ready at joshuamandel.com/regulations.go… Quick summary article here...

GPT 5.4 is *obsessed* with "seams" and "gates". RL is a strange beast.

@paul_ginart I'm not sure about that assumption -- clinicians don't expect everything in the EHR to be perfectly accurate, but they still find it better than nothing, after all!

Just like self driving- this assumes that all data in EHR entered by humans is correct and that bots will not be. Given how much bad chart lore gets propagated and how out of date many EHR components, I’m sure that even accounting for a small agentic hallucination rate, the result will be a net better, cleaner datastore

My regulation.gov browser is up for HTI-5 -- many debates over deregulation! joshuamandel.com/regulations.go…

@0xKhalaf Well, I shelled out the $5 LLM cost to convert all the PDFs and DOCXs to markdown ;-)

@JoshCMandel As an aside, love how I can read comments on a vibe-coded demo page, but accessing the same comment from the government gets me a 5xx.

Direct implications for Health IT licensing -- as HTI-5 proposes AI/RPA as a first-class means of "access"/"use" of health information.

Agentic coding when the nanny calls in sick... prompting by voice is a huge win but also sometimes a liability: › Oh, gross, baby. Do you want to eat that or no? Here, okay, Dada will eat this. No, no. Okay, all right. (Voxtral is *great* for this, BTW.)

Today the SMART Health IT team published our response to ONC's Diagnostic Imaging Interoperability RFI. Quick context: after the imaging provisions of HTI-2 were withdrawn last year, ONC is taking a fresh look at how the certification program should handle diagnostic images. National Coordinator Thomas Keane -- a radiologist -- has made this a priority. The RFI asks whether PACS and VNAs should be brought into the certification program, what standards to adopt, and whether the SMART Imaging Access spec could help. Comments close March 16. The short version of our response: many building blocks already exist (SMART on FHIR, DICOMweb, OAuth token introspection). What's missing is the policy signal that tells the market to wire them together. We make three recommendations. First, ONC should articulate a clear functional vision: patients get a single sign-in covering clinical and imaging data, clinicians get a zero-click launch, backend services get fully automated access, and developers register once. No separate PACS portals, no separate credentials, no separate app registrations. Second, ONC should extend Base EHR certification to cover imaging in a narrow way, with: imaging-specific authorization scopes, actionable metadata (à la FHIR ImagingStudy) with DICOMweb endpoint references, and policy-governed authorization that an external imaging system can enforce without its own identity and authorization policy stack. Third, ONC should create a focused (not "Base EHR") certification criterion for imaging systems: serve DICOM via DICOMweb, rely on the EHR for access policy. That's it. If the EHR side is specified clearly, anyone can build the imaging side -- commercial PACS, open-source proxy, whatever. There's a reason we're pushing hard on functional requirements over technical mandates. We've seen this movie before. A decade ago, EHRs were walled gardens with no standard API. We built the SMART on FHIR spec. The Argonaut Project proved it worked. But what actually drove adoption wasn't the spec -- it was ONC signaling through functional requirements that standardized APIs were the direction of travel. That regulatory pressure gave vendors the cover and the deadline to converge. We're proposing the same playbook for imaging. The Argonaut Project has already demonstrated two viable approaches -- token introspection and "dual SMART launch" -- using today's certified EHR capabilities. ONC doesn't need to pick a winner. Set the functional bar, signal that specific standards will follow in future rulemaking, and let the industry align. smarthealthit.org/2026/03/smart-…

@drchintandave The request is for all EHI... which includes images.

@JoshCMandel Great work on this Josh! One step closer to getting rid of those damn fax machines. Is this able to pull image requests from the EHR, ie. the DICOM data too?

@jeremyhynh I've never gotten any engagement from X articles, but let's try again :) Here: x.com/JoshCMandel/st…

@JoshCMandel y not make an x article?

Every patient has a right to their complete Electronic Health Information -- but there's rarely an API or in-portal button to request it. I built an AI skill that handles the request workflow via fax, finding the right form, filling, signing, and submitting with a cover letter explaining the request in vendor-specific terms. Here's how it works, how to try it, and why I built it as a "Skill" rather than an app. linkedin.com/pulse/i-built-…