Josh Mandel, MD (@JoshCMandel) header
Josh Mandel, MD (@JoshCMandel) profile picture

physician, programmer, and would-be pâtissier/poet. Chief Scientist at @AledadeACO and Architect for @SMARTHealthIT. Bsky: https://teapawt.net/t.co/gZapxtia3H

Madison
Joined June 2012
Photo by Josh Mandel, MD (@JoshCMandel)Photo by Josh Mandel, MD (@JoshCMandel)Photo by Josh Mandel, MD (@JoshCMandel)Photo by Josh Mandel, MD (@JoshCMandel)Photo by Josh Mandel, MD (@JoshCMandel)Photo by Josh Mandel, MD (@JoshCMandel)
Josh Mandel, MD retweeted
Replying to @NKairinos80602
"Can a provider use any agent of their choice to interact with the EHR's UI?" (Today of course, the most common "user agents" -- the technical term for web browsers! -- are fairly dumb but getting smarter fast.)
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Josh Mandel, MD retweeted
I realize this is because thinking traces have gotten too long (and too proprietary) but the solution of hiding them almost entirely so the AI just does "magic" feels like a failure of imagination and a move towards a default of disintermediation that is worth effort challenging.
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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.
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Josh Mandel, MD retweeted
Made using freely available FHIR APIs from open.epic.com.
Today, we’re bringing ChatGPT closer to the systems, information, and workflows healthcare teams already rely on. ♥️ We’re introducing a new EHR integration to connect supported Epic environments to ChatGPT and a plugin connecting to nine additional industry data sources.
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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!
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Josh Mandel, MD retweeted
opus 4.8 with the fable context is some real flowers for algernon shit
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Josh Mandel, MD retweeted
A very important not from @JoshCMandel regarding #TEFCA—for my part, I agree, especially in terms of knowing who is sharing my health information. The framework is doing great for provider to provider communication but... #ASTP2026
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Josh Mandel, MD retweeted
The skill depth of using AI appears to be growing in importance rather than diminishing but the frontier is not “fun prompt tricks” but rather having workflows and, increasingly, a theory of the mind for the tool.
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Josh Mandel, MD retweeted
Fundamentally, the surest way to prevent a bad future is to steer toward a better one that, by its existence, makes significantly worse outcomes harder to achieve. In other words, work towards the better future –– not try to simply stop a particular imagined bad future.
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Josh Mandel, MD retweeted
I recently quit a beloved engineering leadership role to become an IC at DeepMind. I want to become an expert again. the first time I was an expert, I worked my way up. now I'm starting over, but with more to prove & lose. it's terrifying and exhilarating at the same time
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Josh Mandel, MD retweeted
there’s the pre GPT use of the em dash and then there’s the post GPT use of the em dash
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Josh Mandel, MD retweeted
A uniform truth that will play true: in three to five years, we will look back at the infrastructure we're building today and say "how stupid were we". HL7v2, CDA, FHIR...whatever we think is "the" solution will be superseded. And we'll certainly do that about FHIR. Each transition typically happens not because the old standard fails at what it was designed for, but because the underlying assumptions about how systems should interact become obsolete. HL7v2 was built for intra-operability within an enterprise. HL7v3 and CDA was built for exchange between care organizations. FHIR was built for modern app development. FHIR assumes humans (or human-programmed systems) are the primary consumers of healthcare data. So we structure everything around human-readable resources, predefined use cases, and explicit semantic mappings. We spend enormous effort on standardized terminologies, coded values, and structured fields because humans need that scaffolding to interpret and act on the data. It feels like we're almost at that moment and tipping point. The momentum with FHIR will continue and its utility will remain, but so many of the rigid, use case specific pipes we've built will feel silly as we graduate to the next era of exchange - perhaps MCP, perhaps something we haven't thought of yet, but almost certainly a data exchange mechanism that's LLM/AI native. Dumb, flexible pipes become infinitely more valuable than smart, rigid ones. To believe otherwise is to believe we've reached an end state that is not just the local maximum, but the absolute zenith of what's possible. The only truth is that the things we've built will look dumb to the next generation.
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The new USCDI (v6) is here: view.connect.hhs.gov/?qs=be1…
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Josh Mandel, MD retweeted
Summer is in full swing and UGM’s coming up fast. Five thoughts on my mind as we prepare for August:
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Josh Mandel, MD retweeted
One organ donor can save up to eight lives. In the US, early adopters of this feature have seen thousands of donation registrations through MyChart in just a couple of months.
The first hospitals are live on MyChart's new organ donor registration option through @DonateLife. Surveys show that 90% of Americans support donation, yet only 50% have registered. Here's how quickly you can do it in MyChart.
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Josh Mandel, MD retweeted
All the american companies hiding reasoning traces for their models is making the research ecosystem default all of its efforts on using DeepSeek as the "frontier reasoning model" to study. Would be very easy to fix. Gemini's change to remove them is sad and doesn't make sense.
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Josh Mandel, MD retweeted
Replying to @sama
Maybe I'm weird, but I always keep memory off, I like seeing the model's raw capabilities. Can anyone make a case for turning it on?
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in the not-too-distant future, the most complete record of a patient's symptoms may live in the memory of a consumer-facing language model.
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Josh Mandel, MD retweeted
"The AI Revolution in Medicine, Revisited" podcast looks into the reality of AI in healthcare. With coauthors @goldbergcarey @zakkohane, we dissect what we've learned so far in my conversations with doctors, techies, patients, researchers, and policy thinkers.
In Ep. 5 of “The AI Revolution in Medicine, Revisited,” host @peteratmsr & his coauthors @goldbergcarey & Dr. Zak Kohane revisit their earlier predictions about AI in medicine & respond to insights from frontline clinicians, health leaders, & technologists. msft.it/6018SwwRG
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