US Healthcare Interoperability Challenges

We all know that the US Healthcare Interoperability state can be better than it is right now. Let's start with assessing the current state before we analyze the challenges and how we can make meaningful improvements to the same.

Current State

1. TEFCA and CMS Interoperability Framework:
   1. TEFCA implements a 21st Century Cures Act mandate to create a national “network‑of‑networks” with a Common Agreement and uniform policies for cross‑network exchange. CMS Interoperability Framework / CMS‑Aligned Networks is a CMS pledge program, not a statute‑driven network; it invites any qualifying network to publicly commit to higher, aspirational interoperability criteria beyond the legal minimum.
   2. An ONC blog describes TEFCA as “the rising tide that lifts all boats”: it moves the whole ecosystem forward through formal, stepwise policy and governance. Whereas CMS‑Aligned Networks are likened to “speedboats”: early adopters racing ahead on ambitious criteria, rapidly testing and refining new capabilities while TEFCA provides the stable background infrastructure.
   3. Currently, you’ll mostly feel TEFCA and the CMS Interoperability Framework at work as everyday “friction removers” during scenarios like
      1. When you move between doctors or hospitals
      2. At check‑in and registration ('Kill the Clipboard')
      3. In your patient apps and portals (myChart etc.)
      4. During ongoing care and chronic disease management
      5. With payers, authorizations, and benefits (More futurist than current state)
2. Laws, Standards, and Networks: TEFCA and the CMS Interoperability Framework sit on top of a broader stack of laws, standards, and networks that actually make interoperability work day-to-day. These include
   1. USCDI (U.S. Core Data for Interoperability) defines the minimum clinical data set (problems, meds, labs, vitals, SDOH, etc.) that must be consistently exchanged; Draft USCDI v7 is now in development and v3 is the regulatory baseline.
   2. HL7 FHIR and US Core / other IGs specify how data is structured and accessed via modern APIs, so apps and systems can reliably read/write the same resources
   3. The Cures Act and its implementing rules require certified EHRs to support standardized APIs and prohibit “information blocking” (unreasonable interference with data access and exchange).
   4. Existing HIEs and vendor networks (e.g., regional HIEs, EHR vendor networks, private HINs) already exchange large volumes of data via direct connections, CCDs, and FHIR APIs, and many of these are being upgraded but still operate even outside TEFCA
   5. Ongoing ASTP/ONC standards bulletins (like 2026‑1) continually refine USCDI and related standards, guiding how EHRs and APIs evolve over time

Challenges

Now let's talk about the challenges we are still facing on a day-to-day basis.

1. Adoption: Both TEFCA and CMS Interoperability Framework are not mandated by law. TEFCA is widely adopted among major health systems however smaller health systems and independent providers are struggling due to implementation cost and other challenges. Similarly, payers are slowly adopting the CMS Interoperability rules.
2. Complexity: Unintentionally, we have made these initiatives more complex than it needs to be. Ultimately, we need to exchange core data between entities and we could do that without trying to solve for all use cases.
3. Cost: The Cost of implementation has been a challenge too. Especially for providers who are struggling in general. The higher than needed complexity mentioned earlier does not help.  
4. Regulation: Again, with the best intentions, we have ended up overregulating this area and are perpetuating the higher complexity, cost, and lack of adoption. 
5. Alignment of Motivation: This is the underlying challenge of our US Healthcare industry where stakeholders have conflicting motivations between each other and are not aligned when it comes to meaningful exchange of data.

Solution

The best way to solve for this is to find a controlled environment or geography and work with the associated players governed by a shared goal to create a blueprint that takes what's good from the current state but stays focused on building a simple, cheap, not constrained by regulations and a sustainable solution that can be scaled nationally once successfully implemented. An example of such an implementation could be

• Select New England (MA and neighboring states) as the geography we pick for this controlled experiment
• Engage with the providers and payers in this area who are relatively active and affluent to lean in
• Find a boutique implementation partner that is not in this to make easy money but rather get the visibility and be willing to share risk and keep the implementation cost low.
• Work with State legislators and institutions like NEHEN who will be the independent watchdogs to ensure transparency but not be burdened with implementation responsibilities.
• Finally, we will need a well-respected and appointed local executive leader from one of the local providers or payers to own, guide and be the glue to this initiative and provide day to day guidance and support.

Closing Thoughts

Having a working interoperable solution and a support ecosystem for our healthcare system is no longer a 'nice to have' but a 'must have' if we need to make meaningful improvements for the better. The day-to-day friction and abrasion is unbearable and frankly unacceptable. We need all the players to quickly align on a shared goal and do the right thing. If the banks figured out how to allow each other to use their ATM machines to dispense cash for the consumers, healthcare entities can do the same. Let's hope we do it fast and give relief to the patients and help them generate better health outcomes.