How did we get here? – Part 2 of the Healthcare Interoperability blog series

  • July 24, 2023

At major conferences, in news articles, during key meetings, everyone is discussing healthcare interoperability and its potential to revolutionize communications of timely data to facilitate informed healthcare decisions. While it seems like interoperability has only come to the forefront of healthcare discussions recently, the truth is that interoperability efforts have been ongoing for the past decade. The government and healthcare agencies have invested billions of dollars to build the legal and physical infrastructure to make interoperability initiatives possible. It's been quite a journey, and we aren't done yet.

This second blog post in our healthcare interoperability series reviews the key legislative and industry activities that laid the foundation for interoperability today.


Let’s explore the timeline of the steps toward interoperability and why they matter in more detail.

2010 – The HITECH ACT established “Meaningful Use” interoperable Electronic Health Record (EHR) requirements and established the National Coordinator for Health IT (ONC). It gave patients the explicit right to obtain their health information electronically.

Why this matters: This act provides the legal and technical framework for data used in a standardized, meaningful way including certification reviews and oversight. This act triggered the first steps towards interoperability. Without this act, interoperability doesn’t happen.

2012 – The Medicare Blue Button offers Medicare beneficiaries the ability to “download my health data.” Separately, the ONC set up the Standards and Interoperability Framework to standardize data content formats and transport mechanisms.

Why this matters: This was the first demonstrated use of patient self-access to medical records at scale. The Standards and Interoperability Framework emphasized use of data and technical standards in system development through published specifications.

2014SMART and Fast Healthcare Interoperability Resources (FHIR) are introduced. FHIR is a standard for exchanging healthcare information electronically. SMART on FHIR allows standard connectivity between applications and FHIR resources.

Why this matters: SMART and FHIR enabled and supported common application connectivity and required conformance to standards-regulated data, which are fundamental building blocks for interoperability.

2016 – The 21st Century Cures Act makes support for specific Application Programming Interfaces (APIs) a certification requirement for Electronic Health Records (EHRs). EHR manufacturers must build common APIs to support exchanging specific data called U.S. Core Data for Interoperability (USCDI).

Why this matters: This made it possible for nearly all hospital and provider medical systems to support APIs for standardized data regardless of manufacturer. Subsequent versions of the USCDI lexicon expanded the set of mandatory data elements for interoperability.

2017 – The FLAT FHIR bulk data project begins to define bulk FHIR transfer specifications. The CARIN project started the work on a Patient Access API implementation guide.

Why this matters: To launch these projects, industry consortiums were established to address technical challenges and develop implementation guides for standard data interfaces. These two projects built the framework for patients to access their data and created a means to share large amounts of data across systems.

2018MyHealthEData and Blue Button 2.0 are launched. A draft proposal for the Trusted Exchange Framework and Common Agreement (TEFCA) was released.

Why this matters: This shows that CMS and ONC are committed to providing patients with convenient electronic access to their own health data. TEFCA provides a common legal structure for an information exchange super-highway.

2019 – Several HL7 Accelerators begin to work on myriad use cases for interoperability. Patient health records, cancer trials, public health, genomics and social determinants of health all established communities to expand using FHIR within their business domains.

Why this matters: This multi-prong set of use cases expands the value of interoperability to a wider audience of patients and industry, providing a critical mass for adoption and success.

2020 – The Interoperability and Patient Access Final Rule and the CURES Act Final Rule are published. The Act includes Health IT API standards, requires HL7 FHIR in some APIs, and introduces U.S. Core Data for Interoperability (USCDI) to payers as well as providers. Oauth 2.0 and OpenID Connect became the de facto standard for connectivity for consumer healthcare applications.

Why this matters: These acts provided the legislative mandate to give most patients direct electronic access to their health data through a common access method.

2022TEFCA went live in production with six participants. TEFCA provides a legal and technical Health Information Network standard for sharing data.

Why this matters: TEFCA opened the door to federated data sharing between distant systems, although it may have a difficult time identifying a successful long-term business operating model.

2023CMS-0057 Interoperability and Prior Authorization; and CMS-0053 PA and Attachments via X12 6020 are released. These new rules related to Electronic Document Interchange (EDI) and FHIR mandate new HIPAA Attachment transactions that can carry HL7 payloads.

Why this matters: A key result of these rules will be the shift to the system front-end to share clinical and FHIR data using established EDI Gateways to support payer daily business operations. These rules will require architectural and application changes to provider and payer systems to share clinical data with partners who need it for care decisions.

Still work to be done

Significant progress has been made to improve healthcare interoperability, but there's still work to be done. The focus is shifting from back-end data access and reporting to support for critical daily business operations, changing the resources and solutions needed and expanding the possibilities for interoperability.

In our next blog post, we'll explore some of the possibilities and highlight a few of the challenges yet to be solved.

Catch up on the first post in this series or Learn More

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Jeff Strand

As a Senior Business Architect, Jeff interprets changing federal and state legislation and evolving standards into full-featured solutions with an emphasis on user touch points. Jeff has more than 37 years of experience designing, developing, and implementing healthcare processing systems. Recent experience includes implementing the Fast Healthcare Interoperability Resource (FHIR) Application Programming Interface solution in numerous states. Jeff actively participates in Industry Standards Development Organizations and is highly engaged in industry organizations to both contribute to — and learn about — successful 21st century healthcare management.


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