We’re closer than ever to achieving true nationwide interoperability. After decades of fragmentation, false starts, and competing standards, the U.S. finally has multiple national‑scale exchange models taking shape — from TEFCA to CMS‑aligned networks and other emerging frameworks that connect providers, payers, and public health. These efforts share a common goal: making patient data available when and where it’s needed.
While this has ostensibly been the goal of interoperability from the start, what’s different this time is the establishment of a unified, national "network-of-networks" rather than fragmented, voluntary, regional initiatives. Moreover, it includes a renewed focus on empowering patients — improving care coordination, reducing duplicative tests, and enabling easier access to personal health data in one place.
But TEFCA’s progress also highlights a truth that applies across all national exchange models: trust is the foundation. Trust in the rules. Trust in the governance. Trust that participants will use the network responsibly and honor the commitments they’ve made. Without trust, participation falters. And without broad participation, fragmentation returns.
National interoperability isn’t just a technical ambition — it’s a lifeline for rural and community hospitals. These organizations often operate with limited resources, small care teams, and long distances between care settings. When data is siloed or difficult to access, rural providers are placed at a structural disadvantage, forced to navigate gaps in a patient’s history that larger systems can often fill internally. In the worst cases, lack of access to shared data becomes a pressure point that pushes independent hospitals toward consolidation simply to overcome information barriers.
| Robust, trusted national exchange frameworks help level the playing field. Whether TEFCA, CMS‑aligned networks, or others, they ensure that rural clinicians have the same access to timely, complete patient information as their urban counterparts. Protecting trust in these networks is, therefore, not just a policy concern; it’s essential to preserving rural autonomy and the communities that depend on it. If trust becomes optional, interoperability becomes optional. That is the real danger. |
That’s why recent developments that cast doubt on the integrity of national exchange networks are so concerning. TEFCA — like CMS‑aligned networks and other emerging models — was built with a clear governance structure, including a formal process for raising concerns, investigating potential violations, and taking corrective action when needed. These mechanisms exist precisely so that issues can be addressed in a way that strengthens trust rather than eroding it.
A Call to Strengthen National Trust Frameworks
If we want national interoperability to succeed — whether through TEFCA, CMS‑aligned networks, or other emerging frameworks — we need to reinforce the existing trust infrastructure that underpins them. That means strengthening governance, increasing transparency, and ensuring that participants can rely on the network to operate safely and responsibly.
A stronger, more resilient trust framework should include:
| 1. More rigorous and centralized vetting of organizations seeking to exchange data, rather than relying solely on self‑attestation. |
| 2. Clear, accountable onboarding processes that verify business purpose, identity, and legitimacy before access is granted. |
| 3. Ongoing monitoring for anomalous or potentially fraudulent activity, supported by automated detection tools and transparent reporting pathways. |
| 4. Greater transparency into who is exchanging data and for what purposes, including public directories and high‑level activity metrics that help the community understand how the network is being used. |
| 5. Clear, timely, and well‑governed issue‑resolution pathways that ensure concerns are addressed through the framework itself — not through public escalation that undermines trust. |
| 6. Collaboration with federal and state partners to investigate and address intentional misuse, identity fraud, or large‑scale data harvesting. |
Crucially, we must not pause our work on — or our use of — the frameworks as they exist today. We simply cannot afford to wait until we have yet another set of policies agreed upon and implemented to share potentially life-saving data. We already have a governance
These are not controversial ideas. They are the natural evolution of any national‑scale trust framework — the kind of continuous improvements that strengthen confidence, protect patients, and ensure that the network remains a safe and reliable resource for clinicians across the country. Most importantly, they are improvements that should be advanced through the governance processes designed for this purpose, not through actions that destabilize the very networks we are trying to build.
National interoperability is simply too important — for patients, for clinicians, and especially for rural and community hospitals — to allow trust to erode. Strengthening it is not optional. It's the foundation we need to finally succeed.