Building Bridges, Not Silos: The Quiet Rise of Real Interoperability

We Built the APIs. Now What? Reimagining Interoperability Beyond Compliance.

For years, interoperability has been hailed as the White Whale of healthcare technology. Every conference panel mentions it. Every product roadmap aspires to support it. And every stakeholder, from CIOs to clinical end-users, has experienced the friction its absence creates. But is interoperability in U.S. healthcare still just a buzzword, or are we finally approaching a moment where it can become a practical standard?

As someone who's spent over a decade in the trenches of healthcare implementations, I’ve seen both the promise and the pain. The potential of interoperability is undeniable: real-time data exchange between systems, unified patient records, and care teams empowered with actionable insights. Yet, the road to achieving it is paved with regulatory hurdles, legacy infrastructure, competing incentives, and inconsistent data standards.

Understanding the Standards: FHIR, HL7, and CDA

Let’s start by unpacking the technical core. The Fast Healthcare Interoperability Resources (FHIR, pronounced "fire") standard, developed by HL7 International, is designed to simplify healthcare data exchange using modern web technologies. Unlike older HL7 v2 messages or the more document-heavy Consolidated Clinical Document Architecture (CDA), FHIR uses a modular approach. It breaks down healthcare data into "resources"—standardized units like Patient, Observation, MedicationRequest—which can be accessed via RESTful APIs. This structure allows for more scalable and flexible integrations.

FHIR was a response to the limitations of HL7 v2 and CDA, which required more rigid point-to-point integrations and often resulted in siloed systems. With FHIR, developers can build applications that interact with EHRs, patient portals, and third-party tools more fluidly. It brings the health tech stack closer to what we see in modern software development, where APIs drive connectivity and innovation.

But standards are only part of the equation.

Where the Vision Stalls: Hidden Friction Points

Despite the technical advances, adoption remains inconsistent. Many EHR vendors have made progress in exposing FHIR APIs, but they often limit functionality or require proprietary workarounds. And while ONC's 21st Century Cures Act Final Rule mandates open APIs for patient access, enforcement is still catching up to the vision.

Another challenge lies in semantic interoperability—ensuring that the data shared between systems not only transmits but retains the same meaning. For example, one EHR might code a lab test as "Glucose, serum" while another logs it as "Serum glucose." Both refer to the same test, but without harmonized vocabularies like SNOMED CT or LOINC, automated systems may not interpret them as equivalent.

Healthcare organizations also contend with operational barriers. Budget constraints, misaligned incentives between providers and payers, and limited internal resources often stall projects. Even when leadership buys in, the time required to align clinical workflows with new integrations creates additional complexity.

Signs of Progress—and What Comes Next

Still, it’s not all theoretical. We are seeing pockets of real interoperability emerge. Health Information Exchanges (HIEs) have matured. TEFCA (Trusted Exchange Framework and Common Agreement) aims to create a single "on-ramp" for nationwide data exchange. And SMART on FHIR is enabling developers to build applications that plug into EHRs with single sign-on and patient context.

From Vision to Infrastructure: TEFCA’s Role in National Interoperability

The Trusted Exchange Framework and Common Agreement (TEFCA) is a federal initiative led by the Office of the National Coordinator for Health IT (ONC) that aims to establish a unified, nationwide approach to health data exchange. It addresses the long-standing fragmentation across Health Information Exchanges (HIEs) and networks by creating a “network of networks.” At its foundation, TEFCA sets out both the technical standards and legal agreements required for consistent, secure, and efficient data sharing across disparate systems.

A key element of TEFCA is the introduction of Qualified Health Information Networks (QHINs). These entities serve as central hubs, enabling interoperability between organizations that may not have had the infrastructure or agreements to share data directly. By establishing a common baseline of trust, privacy, and technical standards, TEFCA is designed to support seamless nationwide access to health information—advancing clinical care, reducing duplication, and empowering patients. Though still in the rollout phase, it represents a pivotal shift from theory to operational readiness in the push for national interoperability.

High-Impact HIEs Already Making a Difference

Several HIEs across the U.S. have matured into high-impact networks that reflect the vision behind TEFCA. eHealth Exchange connects federal agencies like the VA, DoD, and SSA with thousands of partners nationwide and plays a central role in national data exchange. In the Mid-Atlantic, CRISP—serving Maryland, Washington D.C., and surrounding states—is often cited as a model HIE for its care alerts, PDMP integration, and strong public-private governance.

On the West Coast, Manifest MedEx connects over 30 million records across California, supporting hospitals, ACOs, and health plans with real-time alerts and analytics for value-based care. In New York, Healthix enables statewide clinical notifications and robust public health reporting, playing a pivotal role during the COVID-19 pandemic.

Other standout HIEs include KONZA, which spans multiple states and focuses on payer-provider collaboration and population health infrastructure; NC HealthConnex, which is expanding under a state mandate to support Medicaid transformation and standardized statewide exchange; and MiHIN in Michigan, which serves as a foundational data layer for services ranging from immunization records to social determinants of health. Collectively, these networks prove that scalable, standards-based interoperability is not just aspirational—it’s already in motion.

Real-World Momentum: What Scalable Interoperability Looks Like & What’s Still Holding Us Back?

Organizations that invest in standard-based integrations, prioritize clean and mapped data, and build cross-functional implementation teams are seeing real gains. Patients can view their records through apps of their choice. Providers can get external encounter data at the point of care. Payers are starting to integrate clinical data to close care gaps.

Interoperability may not be fully realized, but it is no longer a myth. The tools exist. The regulations are evolving. The pressure from patients, providers, and the market is intensifying.

The question isn’t whether interoperability is achievable. The question is whether we’re ready to prioritize it across the board—not just in pilot programs or marketing decks, but in budgets, staffing plans, and real-world deployments.

Because when we do, we move from buzzword to baseline.

If you’re building health tech in 2025, interoperability shouldn’t be an afterthought—it should be the design principle. The baseline, not the bonus.