A Call To Action for a Nationwide Interoperable Health IT Infrastructure

Today we are pleased to release Connecting Health and Care for the Nation: A 10-Year Vision to Achieve an Interoperable Health IT Infrastructure.  This paper describes ONC’s broad vision and framework for interoperability and is an invitation to health IT stakeholders – clinicians, consumers, hospitals, public health, technology developers, payers, researchers, policymakers and many others – to join ONC in developing a defined, shared roadmap that will allow us to collectively achieve health IT interoperability as a core foundational element of better care, at a lower cost and better health for all.

Over the past decade, there has been dramatic progress in adoption and use of health IT across the nation.  Through deliberate policy and programmatic action, the majority of hospitals and professionals eligible for the Medicare and Medicaid EHR Incentive Programs has adopted and are meaningfully using health IT. Across the nation, various types of health information exchange show that data can flow and be used to improve care and health.  This progress has laid a strong base upon which we can build.  There is much work to do to see that every person and their care providers can get appropriate health information in an electronic format when and how they need it to make care convenient and well-coordinated and allow for improvements in overall health. 

We have heard loudly and clearly that interoperability is a national priority.  We also see that there is a tremendous opportunity to move swiftly now.  We know that consumers increasingly demand that their data flow and follow them across care settings and beyond.  Payment and delivery system reform are driving a desire from employers, payers, and health systems to share data to reduce redundancy and waste and improve care.  Clinicians are ready for data to enable and inform care and improve their efficiency.  Innovators are stretching our imagination on ways to collect and appropriately use data to improve health.  And evolving technology is providing us with promising new ways to achieve interoperability. 

Achieving this vision will take a strategic and focused effort by the federal government in collaboration with state, tribal, and local governments and the private sector.  We will develop a shared agenda that focuses on five critical building blocks for a nationwide interoperable health IT infrastructure: 

  1. Core technical standards and functions
  2. Certification to support adoption and optimization of health IT products and services
  3. Privacy and security protections for health information
  4. Supportive business, clinical, and regulatory environments
  5. Rules of engagement and governance

These building blocks are interdependent and progress must be incremental across all of them over the next decade to realize this vision.  We will collaboratively develop use cases and goals for three, six and ten-year timeframes that will guide work in each of the building blocks, including alignment and coordination of prioritized federal, state, tribal, local, and private sector actions.

There is no better time than now to renew our focus on an interoperable health IT infrastructure, which includes the following key characteristics:

1)     Allows individuals and care providers to securely search, retrieve, send, and receive essential, electronic health information

2)     Has a sustainable, equitable governance structure that is flexible and resilient

3)     Supports novel data sharing and analysis, including patient-generated data and data from other sources beyond the health care delivery system

4)     Reflects many of the values and concepts in the JASON report, “A Robust Health Information Technology Infrastructure”

We invite you to read Connecting Health and Care for the Nation and offer your feedback and ideas for making the vision a reality.  Over the coming months we will offer several opportunities to provide input as we shape a national interoperability roadmap and encourage participation from all.



  1. Steven E. Waldren, MD says:

    Dr. DeSalvo,

    I appreciate the focus on interoperability. It and usability are the two biggest HIT issues for family physicians (and likely other providers). We stand ready to continue the work needed by your call to action.

    Of the five critical building blocks, I think #4 should be #1, as this misalignment of business incentives is likely the biggest barrier to real interoperability. Without that alignment, I have seen a “check the box” mentality to achieving interoperability when blocks #1,#2,#3 are in place. Channeling Steve Posnack from the FDASIA meeting at NIST, “Interoperability for what…” The “for what” cannot be compliance with regulation; it must be to drive business value which must be tied to the Three Part Aim.

    To take the “for what” a little further, we need interoperability for (1) Communication, (2) Collaboration, and (3) Changing products.

    On the communication front, we have been helping the movement a foot to provide interoperability through the use of Direct, which aligns with the guiding principles of using existing HIT infrastructure, leveraging the market, and simplify. We need to continue the momentum to create a network to support any provider sending a secure message to any other provider. We are almost there!

    On the collaboration and changing products front, we need open APIs that vendors make available to allow other products and services to integrate with them.

  2. George Kim says:

    In Figure 1 on Page 2 of the linked document “Health IT Ecosystem”, should the loops for Public Health and Public Health Policy not be interchanged with the ones for Clinical Research and Clinical Guidelines?

  3. Dr. Stephen Beller says:

    I’ve been involved with the interoperability issue since the Federal government’s ONCHIT call for proposals, ten years ago, for the National Health Information Network (NHIN). At that time my company submitted a proposal for a secure, economical solution for the exchange of health information between patients, providers, researchers, and public health agencies that uses encrypted e-mail over the internet (SMTP with S/MIME) in peer-to-peer, publish/subscribe mesh node networks.

    For the past decade, we have been working diligently for the realization of this vision. We have, for example, participated as committed members in ONC workgroups (i.e., Direct project, S&I Framework initiatives, and 360X); written to Congress; engaged with patient privacy rights groups; replied to requests for information; and developed software applications able to demonstrate the viability of our proposed complete and economical, standards-based (not vendor-based) interoperability solution.

    Sadly, it has been a struggle all the way for political and business layer reasons (not for technical reasons).

    Nevertheless, there has been recent progress in the right direction, such as MU2’s requirement for the Direct project’s “Simple SMTP” transport capability and for the use of data standards (e.g., C-CDA).

    Now, while ONC’s recent publically stated commitment to interoperability is a step in the right direction, too much time (and money) has been wasted and there is no need to wait another 10 years for interoperability. Given the political will, it can be achieved in just a couple of years, at minimal cost, using technology that already exists, such as e-mail clients and PKI.

    It appears to me that the biggest challenges to interoperability include:
    • EHRs vendors that do not want to share patient information they store with authorized parties that use other EHRs and thus refuse to comply with the MU2 requirements
    • Use of transport methods that do not adequately protect patient privacy by allowing the PHI to be decrypted as it passes from sender to receiver
    • Regulatory capture that stifles creative destruction through regulations that block disruptive innovation and that fail to support such innovations financially.

  4. Laurel Neufeld-Williams says:

    Please consider taking into consideration the structure of various forms of EHR’s. As a nurse working at a hospital, we have used 3 different software programs and the format in each is different. I am very concerned about trying to view narrative comments in patient’s medical records. In my experience, those comments are the only thing that individualizes patients and tell a vital story. However, not only is it difficult to locate some of the comments, I have no idea where they show up if the medical record is ever printed. Interoperability should consider that fact as well

  5. Mattie Lowery says:

    Resplendent achievable vision

    ONC’s broad vision and framework for interoperability is excellent and what I believe as a previous IT Clinical Systems Manager will provide a unifying secure infrastructure for interoperability…the greatest undertaking organizations have in implementing EHRs from a safety, cost, and functionality perspective (since “one size” does not fit all).

  6. Dr J says:

    I would disagree with the assessment to build on top of existing IT infrastructure and extend where needed. We are where we are today and not further along due directly to those involved in the organizations that have created the existing standards, which tend to be the same individuals across the different groups. This is then further compounded by those same people being part of the S&I framework initiatives and also used as contractors by ONC and CMS. There is no critical review of these standards by those outside of these institutions and ONC/CMS do not have the technical expertise internally to understand them so they rely on their contractors to guide them, which happen to be the same people that create the standards. This is extremely bad practice.

    ONC and CMS have had an unhealthy reliance on the outside consultants that make up these “standards” bodies for some time. Any standard for use, including the existing ones that are written into law, should be fully vetted by technical experts in the field of interoperability, not by the same collective mind share that has led us down the wrong path for the past 15 years. Only then can we be sure that the standards impose on the healthcare industry do what they are meant to do in a way that is clear and easily understandable, unlike the existing mess we have now.

  7. Nick Williams says:

    This happening is inevitable. How long it actually takes to fully implement is anyone’s guess, but it needs to happen.

  8. Han Terner says:

    I’m writing article about the best interoperability of health systems around the world. I’m trying to compare IT health systems with totally chaotic system created in my country.
    I’m also a customer of this systems – as a person with chronic disease – and I know how helpful all-in-one systems would be for doctors and patients.

    Today interoperability of IT systems is one of the most important feature – it should be extended as much as it can. We should remember that there are more and more autonomous systems and softwares used in any kind of our life and joining them together would improve the quality and time of their use.

    Unfortunately, in my country there is a problem very closed to the information Dr. Stephen Beller gave in his comment. We have the possibility and technical opportunities to extend IT infrastructure and improve interoperability of used software. The problem are: political and business layer reasons.

    Thank you for this great example of working on usability improvement of those systems, it will surely help me to create a plan for expanding my country’s systems which will be involved in my article work.

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