Healthcare Interoperability

Healthcare interoperability is the ability of different health information systems, devices, and applications to access, exchange, integrate, and cooperatively use data in a coordinated manner. In the United States, interoperability requirements are driven by federal regulations, particularly the 21st Century Cures Act and the rules promulgated by the Office of the National Coordinator for Health Information Technology (ONC) and the Centers for Medicare and Medicaid Services (CMS).

Standards Landscape

The healthcare interoperability ecosystem comprises multiple standards, each addressing different aspects of data exchange. Understanding which standard applies to which use case is essential for implementation planning.

StandardPrimary UseFormatStatus
HL7 FHIR R4Modern API-based clinical data exchangeJSON / XML / RDFONC required (US Core)
HL7 v2.xHospital system interfaces (ADT, orders, results)Pipe-delimited textWidely deployed, mature
C-CDA (HL7 CDA R2)Clinical document exchange (discharge summaries, referrals)XMLRequired for Meaningful Use
DICOMMedical imaging storage and transferBinary / DICOM JSONUniversal in imaging
NCPDP SCRIPTElectronic prescribingXMLRequired for e-prescribing
X12 (ASC X12N)Administrative transactions (claims, eligibility, authorizations)EDIHIPAA mandated
Direct MessagingSecure point-to-point clinical messagingS/MIME over SMTPONC certified
IHE ProfilesCross-enterprise workflows built on FHIR, CDA, DICOMMultipleImplementation guidance

21st Century Cures Act

The 21st Century Cures Act (Public Law 114-255), signed into law on December 13, 2016, includes significant provisions for health IT interoperability. Title IV of the Act addresses health information technology and specifically targets information blocking, patient access, and the use of open APIs for health data exchange.

Key Provisions

  • Defines and prohibits information blocking by health IT developers, health information networks, and health information exchanges
  • Requires HHS to adopt standards for APIs that enable patient access to their electronic health information
  • Establishes conditions and maintenance of certification requirements for health IT developers
  • Authorizes the Trusted Exchange Framework and Common Agreement (TEFCA)
  • Defines Electronic Health Information (EHI) as information in designated record sets per HIPAA, plus other information identified by the Secretary

ONC Cures Act Final Rule

Published on May 1, 2020 (85 FR 25642), the ONC 21st Century Cures Act Final Rule implements many of the Cures Act requirements. The rule establishes requirements for certified health IT, defines information blocking, and adopts standards and implementation specifications.

RequirementStandard / SpecificationNotes
Standardized API for patient servicesHL7 FHIR R4, US Core IG, SMART App LaunchPatients can access their EHI via third-party apps
Clinical data contentUSCDI (US Core Data for Interoperability)Defines minimum data classes and elements for exchange
Clinical document exchangeC-CDA R2.1Consolidated Clinical Document Architecture
Vocabulary standardsSNOMED CT, LOINC, RxNorm, ICD-10-CM, CPT, CVXRequired code systems for structured data
TransportDirect Messaging (v1.1), FHIR HTTP RESTSecure transport mechanisms for health data
Patient identityHL7 FHIR R4 Patient resourceDemographics-based matching in absence of national patient ID

TEFCA

The Trusted Exchange Framework and Common Agreement (TEFCA), authorized by the Cures Act, establishes a universal floor for interoperability across the US. ONC designated the Sequoia Project as the Recognized Coordinating Entity (RCE) to develop, implement, and maintain TEFCA.

TEFCA Components

  • Common Agreement -- The legal framework and technical requirements that Qualified Health Information Networks (QHINs) must follow
  • QHINs -- Qualified Health Information Networks that have signed the Common Agreement and meet technical, security, and privacy requirements
  • Exchange Purposes -- Defined purposes for which exchange can occur: Treatment, Payment, Health Care Operations, Public Health, Government Benefits Determination, Individual Access Services
  • QHIN Technical Framework (QTF) -- Technical specifications for QHIN-to-QHIN exchange, including message formats, security, and trust requirements
  • Standard Operating Procedures (SOPs) -- Detailed operational procedures for specific exchange workflows

Information Blocking

The Cures Act defines information blocking as practices that are likely to interfere with, prevent, or materially discourage access, exchange, or use of electronic health information (EHI). The information blocking provisions apply to three categories of actors: health care providers, health IT developers of certified health IT, and health information networks and health information exchanges.

ExceptionCFR ReferenceDescription
Preventing Harm45 CFR 171.201Practices reasonably necessary to prevent harm to a patient or other person, if applied consistently and not broader than necessary
Privacy45 CFR 171.202Practices that protect patient privacy, if the practice is required by law, the patient has not consented, or other qualifying conditions
Security45 CFR 171.203Practices directly related to safeguarding EHI, if tailored to specific security risks and implemented consistently
Infeasibility45 CFR 171.204Practices where compliance is infeasible due to uncontrollable events, technical limitations, or segmentation challenges
Health IT Performance45 CFR 171.205Practices to maintain or ensure health IT performance, if applied consistently and for a limited time
Content and Manner45 CFR 171.301Limiting content or manner of access/exchange if alternate means are offered and response is timely
Fees45 CFR 171.302Charging fees that are reasonably related to costs, not based on competitive factors, and not tied to exchange direction
Licensing45 CFR 171.303Licensing terms that are reasonable, non-discriminatory, and allow for interoperability

USCDI (US Core Data for Interoperability)

USCDI defines the minimum set of data classes and data elements that are required for nationwide interoperable health information exchange. ONC publishes updated versions of USCDI through a public process. USCDI v1 was adopted in the Cures Act Final Rule; subsequent versions (v2, v3, v4) add additional data classes.

Data ClassData Elements (examples)Since
Patient DemographicsName, Date of Birth, Sex, Race, Ethnicity, Address, Phone, Emailv1
Allergies and IntolerancesSubstance (RxNorm/SNOMED), Reaction, Severityv1
MedicationsMedication name (RxNorm), Dosage, Route, Frequency, Fill statusv1
ProblemsCondition (SNOMED CT/ICD-10-CM), Date of diagnosis, Statusv1
ProceduresProcedure (SNOMED CT/CPT/ICD-10-PCS), Date, Reasonv1
LaboratoryTest (LOINC), Result, Units (UCUM), Reference range, Datev1
Vital SignsBP, Heart rate, Respiratory rate, Temperature, Height, Weight, BMI, SpO2v1
Clinical NotesConsultation, Discharge summary, History & Physical, Progress, Procedure notesv1
Health ConcernsSDOH data, Functional status, Disability status, Mental healthv2
GoalsPatient goals, SDOH goalsv2
Diagnostic ImagingImaging study (DICOM), Reportsv3

Regulatory Sources

The ONC Cures Act Final Rule is published at 85 FR 25642. The information blocking regulations are codified at 45 CFR Part 171. TEFCA materials are maintained by the Sequoia Project at rce.sequoiaproject.org. USCDI versions and the public comment process are available at healthit.gov/uscdi. CMS interoperability rules (CMS-9115-F, CMS-9123-F) cover payer-to-payer exchange and patient access APIs.