An In-depth Guide to EHR Interoperability

EHR Interoperability

Electronic Health Records, or EHR, are digital libraries that house invaluable patient medical history data. From clinical observations to diagnoses, medications, and immunization schedules, it’s all there, at a healthcare provider’s fingertips.

But what about when these EHR systems need to ‘talk’ to one another? That’s where EHR interoperability comes in. Simply put, it’s the capability of different EHR systems to share, interpret, and collaboratively use data across various healthcare environments. 

Imagine a healthcare landscape where a patient’s health data isn’t scattered across multiple systems but smoothly flows from one EHR system to another. An environment where physicians, no matter where they are, can access a patient’s complete medical history at a moment’s notice and make the best-informed decisions. 

In fact, such interoperability isn’t just nice to have. It’s a game changer that can lead to more efficient healthcare systems and better patient outcomes. EHR Interoperability can help institutions save money but also helps in saving lives and improves patient care. One study reported that up to 18 % of patient safety events (PSEs) could be attributed to EHR interoperability issues.

Ready to delve deeper? Let’s navigate the world of EHR interoperability together.

Table of Contents

  1. Understanding EHR Interoperability
  2. The Importance of EHR Interoperability
  3. Standards for EHR Interoperability
  4. Recent Developments in EHR Interoperability
  5. The Hurdles in Pursuit of EHR Interoperability
  6. Overcoming Interoperability Challenges
  7. Why You Should Consider EHR Interoperability
  8. The Road Ahead: The Future of EHR Interoperability
  9. Conclusion

Understanding EHR Interoperability

EHR interoperability or interoperability in healthcare in general is all about connecting the dots in healthcare. It’s about enabling different EHR systems to communicate, exchange data, and use the information that has been exchanged. This functionality offers an integrated and holistic view of a patient’s health data, which can significantly enhance care delivery and outcomes.

To give you a clearer picture, let’s break down the different levels of interoperability:

1. Foundational Interoperability

This is the most basic level, allowing data exchange from one information technology system to be received by another. It does not require the ability to interpret the data.

2. Structural Interoperability

This is an intermediate level that defines the structure or format of data exchange (i.e., the message format standards) where healthcare data is uniformly moved from one system to another.

3. Semantic Interoperability

This is the highest level, which allows for data exchange and the use of the information by the receiving system. It provides the ability to exchange clinical health information and use it meaningfully. 

In essence, achieving EHR interoperability means reaching the semantic level. At this stage, data isn’t just shared and exchanged; it’s also understood and used in a cohesive manner to enhance healthcare outcomes.

4. Organizational Interoperability

The fourth level of interoperability is new and is added by the HIMSS (Health Information and Management Systems Society). This level determines the importance of bringing all levels together. Organizational interoperability includes standard operating procedures, governance, social and legal considerations, and policies that are essential for data privacy and governance in an organization. This level brings out the trusted exchange framework mentioned in the 21st Century Cures Act and emphasizes on the trust aspect in data exchange.

In the next sections, we’ll delve into why EHR interoperability is essential and the challenges you might face in achieving it. Stick around as we unravel the complexities and promise of EHR interoperability!

The Importance of EHR Interoperability

When we talk about the importance of EHR interoperability, we’re talking about creating a more connected, efficient, and adequate healthcare ecosystem. This isn’t just about technology or systems; it’s about you, your peers, and, most importantly, your patients. 

With interoperability, you can comprehensively understand a patient’s health history. You no longer need to be a detective, searching for clues in multiple systems and piecing together a fragmented story. EHR interoperability allows different systems to ‘speak the same language,’ bringing all the information together in one place. This means that you can make well-informed decisions quickly, enhancing the quality of patient care.

The advantages don’t end there. EHR interoperability leads to more streamlined processes and enhanced productivity. By cutting down on the time and effort spent reconciling information from different sources, your teams can focus on what truly matters: patient care. 

Beyond individual healthcare providers, interoperability in EHR software development has public health implications. With interoperable systems, health departments can quickly gather data to monitor health trends, track disease outbreaks, and coordinate response efforts.

Ultimately, it acts as a master key that opens the door to a healthcare system that is more efficient and effective and centered around the patient. As we cast our eyes forward to a horizon where healthcare embodies seamless integration and genuine patient focus, the role of EHR interoperability becomes more than just significant – it becomes indispensable.

Standards for EHR Interoperability

Interoperability is all about seamless data exchange, so to attain that stage regulatory bodies have developed certain data exchange standards. These standards ensure smooth transfer of information, and maintain privacy and security of ePHI as well. The key for successful EHR interoperability is to understand each of these standards and which one suits you the best. Widely used standards in today’s time are:


FHIR (Fast Healthcare Interoperability Resources) standard revolves around API that assists in efficient data exchange between EHR, and amongst other healthcare systems. FHIR has become of the popular standards for enabling structural and semantic interoperability.

EHR vendors are investing in FHIR as a leading method for data exchange because it offers flexibility and scalability in data exchange. It is one standard that brings all organizations on one platform of information exchange. Furthermore, ONC final rule calls health IT developers and healthcare providers to exchange data using FHIR-based APIs and third-party applications.


SMART on FHIR is a context for building application on top of FHIR APIs. What exactly SMART on FHIR does is that it allows developers to develop applications that are launch on EHR or web portals.

In layman’s language, if a developer uses this standard then to connect with multiple EHRs, provided they support FHIR framework. So, the application launched is just plug and play. Find out more on SMART on FHIR here.

3. C-CDA

C-CDA (Consolidated-Clinical Document Architecture) was created by HL7, ONC (Office of National Coordinator for Health Information Technology), HIE (Integrating the Healthcare Environment), and the Health Story Project. HL7 states that C-CDA provides a library of templates and prescribes their use for specific document types.

Further, this standard offers a single source of CDA (Clinical Document Architecture) templates for 12 structured and one unstructured document type. CDA is basically a standard that defines semantics and structure of clinical documents for data exchange. Healthcare providers utilize C-CDAs to send consultation notes, continuity of care documents, discharge summaries, diagnostic imaging reports, and other documents for clinical decision-making.


ONC’s Health IT Certification Program mandates the use of USCDI (United States Core Data for Interoperability). It is a standardized set of health data classes and constituent data elements such as allergies, clinical notes, intolerances, lab tests, and medication nationwide. CMS addresses certain core elements of USCDI which are:

  1. It comprises core set of data needed to support patient care and facilitate patient access using health IT.
  2. It expands overtime through transparent, predictable, and collaborative public procedure.
  3. Establishes a constant baseline of data for other use cases.

USCDI+ is a service for federal partners who need to harmonize, establish, and use interoperable datasets. It expands beyond the core data in the USCDI.

5. HL7 Version 2 Integrations

HL7 V2 is a push-based message system and it covers a wide range of data, thus making it an excellent choice for several application uses. It has the ability to offer real-time notifications within EHR systems such as appointment check-ins. One of the challenges of this standard is that it can be extremely variable. EHR vendors may end up choosing different variations that can result in complicated integrations.

6. CDA

CDA (Clinical Document Architecture) is a standard developed by HL7. It defined the structure of specific medical records such as progress notes and discharge summaries, as a way to exchange information in a better way between patients and providers. Documents include data like text, images, and other multimedia.

CDA is based on XML (Extensible Markup Language) and it uses HL7’s RIM (Reference Information Model) to represent health concepts. With XML and RIM, CDA allows EHRs to process documents, so people can read them easily on browsers or mobiles.

7. Proprietary EHR APIS

These are private APIs published by some health records. They can be critical to your integration if your EHR supports a private API capability that is not supported by a public API. For example, if you’re writing an allergy, scheduling an appointment, or posting a payment made by a patient, these could be the tools you’re using. However, these tools come with restrictions, such as non-standard data models and costs.

8. CDS Hooks

CDS (Clinical Decision Support Hooks) describes the RESTful APIs and interactions to integrate CDS between EHRs/health information systems and CDS services. Data exchanged via RESTful APIs is sent and received as JSON structures and is transmitted over secured channels using HTTPS over TLS (Transport Layer Security). User activity in organization’s EHR triggers CDS Hooks in real-time. Examples include:

  1. Order-sign on seeing the pending orders for approval.
  2. Order-select for new prescription
  3. Patient-view for opening a new record


DICOM (Digital Imaging and Communications in Medicine) is a standard for storing, transmitting, printing, retrieving, and sharing medical imaging. It is not directly related to electronic health records, but it plays a vital role in interoperability and in integrating imaging data into EHR.

10. OpenEHR

This is an open-source standard for EHR data. It utilizes two-level modeling approach, for vendor-neutral and flexible data storage. OpenEHR not only defines ‘what’ and ‘how’ to share a data, but it also answers ‘why’ to share. FHIR is for data exchange, whereas OpenEHR is for data storage and modeling.

11. Blue Button 2.0

This is an application programing interface from the CMS that allows Medicare beneficiaries to connect their healthcare data to services, applications, and research programs that they trust.

Recent Developments in EHR Interoperability

EHR interoperability can be best understood by keeping on par with the recent happenings around the country.


In December 2023, the HHS (U.S. Department of Health and Human Services) through ONC announced that the nationwide health data exchange governed by the TEFCA (Trusted Exchange Framework and Common Agreement) is not operational. TEFCA allows providers, patients, public health professionals, health insurers, and healthcare stakeholders to securely and safely share information.

Common Agreement Version 2.0 that is predicted to include updates for HL7 FHIR based transactions, it is under development and is scheduled to be adopted by QHINs (Qualified Health Information Networks) in the first quarter of 2024.

Organizations designated as QHINs are:

  1. Epic Nexus
  2. eHealth Exchange
  3. Health Gorilla
  4. MedAllies
  5. KONZA

These QHINs are a robust support of TEFCA network-to-network exchange, offering governance and services to safely route responses, queries, and messages across systems.

2. AI Transparency, Interoperability Rule

Known as the Health Data, Technology, and Interoperability: Certification Program Updates, Algorithm Transparency and Information Sharing, or the HTI-1, includes vital provisions of the 21st Century Cures Act, emphasizing on health IT certification and information blocking.

The new regulation creates new risk management and transparency expectations for AI and machine learning tech that helps with decision-making in healthcare. HTI-1 provisions addresses clinical decision support and decision support interventions. The rule seeks to increase trustworthiness and transparency of predictive algorithms with the goal of supporting their wide usage in healthcare.

The regulation mentions USCDI Version 3 as the new baseline standard within the ONC Health IT certification program as of January 2026. New USCDI version 3 updates is focused on accurate and complete patient traits data that helps to promote equity, support public health data interoperability, and reduce disparities.

The Hurdles in Pursuit of EHR Interoperability

As we set out on the journey toward successful EHR implementation, it’s essential to acknowledge and understand the roadblocks that might appear on the way. By recognizing EHR interoperability challenges, we can strategize effectively to overcome them and truly harness the transformative potential of EHR interoperability.

1. Lack of Data Standardization

Consider this – we have a multitude of EHR systems, each with its unique way of recording and storing data. It’s akin to trying to assemble a jigsaw puzzle where every piece comes from a different set. While they’re all part of the bigger picture, the subtle differences make piecing them together quite an endeavor.

2. Privacy and Security Concerns

In an era where data is shared across various platforms, the risk of security breaches looms large. As healthcare providers, we’re trusted with the health and our patients’ personal data. Ensuring the safety of this data during exchanges and storage becomes a crucial responsibility.

3. Technological and Financial Constraints

The process of integrating diverse systems can be complex and resource-intensive. It requires a substantial investment of time, effort, and funds. This can be especially challenging for smaller practices that may be financially constrained.

Pathways to Triumph Over Interoperability Challenges

While these challenges may seem daunting, there are effective strategies available to navigate this landscape successfully. Here’s a roadmap to address these issues and fully leverage the benefits of EHR interoperability:

1. Standardization of Data 

The first crucial step is to foster health information exchanges (HIEs) and ensure compliance with established data standards like HL7. Although it may seem like a herculean task, aligning your systems with these standards can substantially ease the data exchange process and enhance overall interoperability.

2. Robust Data Protection Measures

When it comes to allaying privacy and security concerns, robust data protection measures are a must. This includes implementing secure data transmission methods, establishing stringent access controls, and conducting regular security audits. In our digital age, where cyber threats are rampant, prioritizing the security of patient data is non-negotiable.

3. Overcoming Technological and Financial Barriers

Addressing these barriers requires strategic investments in interoperable technology. Consider forging alliances with EHR vendors that prioritize interoperability and offer ongoing technical support. While this might necessitate higher upfront costs, the long-term dividends in enhanced efficiency, improved patient satisfaction, and better health outcomes render it a worthwhile investment.

While the path to EHR interoperability is paved with challenges, remember that it’s a journey that leads to an enriching destination – an integrated, efficient, and genuinely patient-centered healthcare system. As we stride forward to this future, EHR interoperability ceases to be a mere objective and transforms into a fundamental necessity.

Why You Should Consider EHR Interoperability

Now that we’ve walked through the what, why, and how of EHR interoperability, let’s address the most crucial question: Why should you consider it a healthcare provider?

  1. Enhanced Patient Care: EHR interoperability facilitates a holistic view of the patient’s health, allowing for more accurate diagnoses, personalized treatment plans, and improved health outcomes.
  2. Operational Efficiency: By cutting down on manual data entry and reconciliation, interoperability can significantly boost your organization’s operational efficiency, freeing up your staff to focus on patient care.
  3. Financial Benefits: As noted earlier, the financial implications are significant. With the potential to save the healthcare sector over $77 billion annually, the financial argument for interoperability is compelling.
  4. Patient Satisfaction: In today’s digital age, patients expect seamless experiences. Interoperability can greatly enhance patient satisfaction by providing easy access to their health records and enabling smooth transitions between providers.
  5. Public Health: On a larger scale, EHR interoperability aids public health efforts by enabling quick data gathering to monitor health trends and coordinate responses to health emergencies.

The Road Ahead: The Future of EHR Interoperability

The future of EHR interoperability looks promising, fueled by advancements in technology and a growing recognition of its potential benefits. Here’s a look at what lies ahead:

1. Greater Adoption of Interoperable Systems

As the advantages of EHR interoperability become more apparent, we can expect to see a surge in its adoption across healthcare organizations of all sizes. This is not merely a prediction but a trend that is already being witnessed. A report by Reaction Data revealed that 86% of healthcare organizations consider interoperability as their top priority.

2. Evolving Standards

Expect to see continuing evolution and refinement in data standards. This ongoing progress will make interoperability more seamless, easing the information exchange process.

3. Increasing Emphasis on Security

As more data is shared across platforms, security measures will become even more robust. Healthcare providers will increasingly adopt sophisticated encryption methods and stringent access controls to safeguard patient data.

4. Patient Engagement

The interoperability of EHRs will empower patients by giving them greater control over their health data. Patients can contribute to their health records and access them across numerous providers, creating a genuinely collaborative approach to healthcare.


As we’ve explored, EHR interoperability is not just a lofty ideal; it’s a pragmatic and necessary step towards a connected, efficient, and patient-centric healthcare future. As we move towards this inevitable future, the decision to embrace EHR interoperability is not just a choice but an essential strategic move.

As a healthcare provider or a HealthTech startup, you’re a catalyst for this transformation. Your role in this journey is crucial, but you’re not alone. This path may seem daunting with the challenges of integration, data standardization, and security concerns. But it’s here that Arkenea steps in.

With over 14 years of specialized expertise in the healthcare industry, Arkenea is a trusted partner for healthcare organizations seeking to navigate the complex landscape of EHR. As a custom healthcare software development company, Arkenea offers scalable, secure, and compliant software solutions tailored to your unique needs.

Whether you’re a healthcare organization looking to enhance patient care and operational efficiency or a HealthTech startup aiming for digital success, Arkenea can provide the technical prowess and industry insight you need to make the most of EHR interoperability.

At Arkenea, we’re not just about building software but about forging partnerships and driving healthcare transformation. Together, we can unlock the true potential of EHR interoperability and shape the future of healthcare.

Contact Arkenea today to take the first step on this exciting journey towards a future defined by EHR interoperability, enhanced patient care, and digital success.