Where healthcare stands on interoperability in 2026: progress and challenges

TEFCA achieves key milestones

Health IT professionals can no longer discuss interoperability in healthcare without considering TEFCA, the federal initiative intended to enable data exchange across health information networks. In December 2023, TEFCA went live, sparking the designation of Qualified Health Information Networks (QHINs).

By February 2026, nearly 500 million health records had been exchanged through TEFCA, up from 10 million in January 2025, according to the Office of the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health IT (ASTP/ONC).

Just a month later, that number is up to 600 million, Mariann Yeager, CEO of The Sequoia Project, said in a HIMSS session on Tuesday. The Sequoia Project is the Recognized Coordinating Entity (RCE) for TEFCA, meaning it is responsible for developing, implementing and maintaining the Common Agreement component of it. It also works with ASTP to designate QHINs.

"TEFCA is going from being in development mode to implementation rollout," Yeager said in an interview. "We saw tremendous growth in 2025."

To Yeager, that rapid growth makes sense, given that 11 QHINs have been designated since TEFCA went live at the end of 2023, and those QHINs are now bringing their connections on board and ramping up data exchange.

"Once you do those things and you prove that the connections work and that they fit within workflow, and then people start using it, that's a natural trajectory," Yeager said. "It's so important to note the speed at which adoption has occurred. And in other earlier iterations of trust framework approaches, it took a lot longer. So, I think that shows a maturation, which is really important."

Other progress made under TEFCA, Yeager explained, includes the formation of the TEFCA QHIN caucus, the TEFCA cybersecurity council and the TEFCA participant/subparticipant caucus. These caucuses were designed to give stakeholders a way to provide input and vote on changes, encouraging feedback and iterations.

A true milestone was achieved, Yeager suggested, when the RCE established its governance procedures.

"Once people started exchanging information, that triggered the formation of a transitional governance structure, and there was a defined timeframe to stand up more fully established governance with the caucuses and the governing council. And that took place in early 2025 and they immediately mobilized," Yeager said during the session.

"In a matter of months, they informed policy development, and they provided feedback on important use cases on individual access and treatment."

Yeager highlighted significant progress on expanding TEFCA's footprint and increasing transparency and engagement as TEFCA settles into its implementation phase.

"We always want to make sure that TEFCA is not theoretical, it's not philosophical. It really is about getting boots on the ground for exchange to occur," Yeager said.

CMS interoperability framework moves the needle

The CMS interoperability framework, which was established in July 2025 as part of a broader initiative out of the White House to promote the nation's health IT capabilities, has also pushed interoperability forward. The voluntary framework requires participating entities to provide or facilitate access to data using FHIR APIs and provide appointment notifications using FHIR subscriptions.

Entities that voluntarily meet the CMS criteria would become "CMS aligned networks" if they showcase the criteria objectives in the first quarter of 2026, CMS said at the time. In March, Clover Health became the first payer to go live on a CMS aligned network.

"CMS is trying to make a lot of progress, even though they know it's not going to be perfect, but they're trying to really move the needle, and we're seeing that," Edward Yurcisin, chief technology officer of the National Committee for Quality Assurance (NCQA), said in an interview.

From Yeager's point of view, CMS' interoperability focus has positively elevated the issue of interoperability, with the initiative serving as a complement to Sequoia's efforts as the RCE to promote TEFCA.

"I think it's exciting to see that kind of leadership. It's important. When you have high-level officials talking about this issue, it shows that it's not just a technical issue. This is strategic, and we all need it to work," she said.

Aashima Gupta, global director of healthcare at Google Cloud, also expressed appreciation for the framework.

"I'm very encouraged by the work CMS is doing, especially the interoperability pledge and mandating having API-level access for the common clinical data set," Gupta said in an interview. "So, that was very encouraging from a regulatory standpoint."

The CMS interoperability framework is still in its early stages, but experts suggest that CMS amplifying interoperability and encouraging participation in FHIR-based exchange has the potential to contribute positive change.

Priority areas of improvement

The progress made toward interoperability is significant, as exemplified by the growing number of QHINs, records exchanged and interoperability framework signees.

"I think we're making huge progress on interoperability, because organizations have now concluded that FHIR is going to be the exchange standard, which is fantastic," Yurcisin said. "We've come a long way. You can now look at Apple Health and see all the EHR implementations that support Apple Health. You can start to really see the exchange of data."

Still, there are several pressing challenges to address in the near- and long-term.

NCQA is a private, nonprofit organization that measures the quality of health plans, providers and practices using the Healthcare Effectiveness Data and Information Set (HEDIS). As such, Yurcisin is particularly focused on data quality issues when it comes to interoperability.

"To have true interoperability is to have high-quality data, because requiring the FHIR API is nice, but what may be coming out of that may not be clean. That’s something we are working on," Yurcisin said.

"I think it has to start with improving data quality at the source, but then organizations may inadvertently as they're combining data and moving data, also introduce errors and so forth."

Yurcisin noted that while attributes like conformance, completeness and plausibility -- factors used to evaluate and compare data quality -- are often highlighted as keys to ensuring high-quality data, the technical implementation can be complex. It's a hurdle that the industry is still working through, he said.

Under TEFCA, Yeager pointed out challenges in fostering adoption of individual access services, a function that allows patients to electronically request and receive their own health information.

"There is a work stream underway now to continue working on that," Yeager said. "Specifically what we're learning is that the community really believes that FHIR-based exchange is really the best way to enable individual access services. That more work is needed to fully standardize and have more credentialed identity traits to improve match results so that there's confidence that the individual who's query records will only get the records that pertain to them and not someone else."

Another near-term priority that Yeager noted is making progress specifically around FHIR-based exchanges.

To Gupta, there is room for AI in the interoperability conversation, because AI models can comprehend unstructured data in various formats.

"From a technology standpoint, when we talk about the FHIR standard or a different format, and you think about a frontier model like Gemini, it's able to understand it -- it doesn't need to be a very structured format for it to understand," Gupta said.

"So, models have the sophistication, the context and the reasoning -- that is good news for interoperability. Second, we can actually map the data from a different format to a FHIR format much more easily."

AI could help advance interoperability by making it easier to integrate and translate unstructured data sources, without depending on strict formatting.

Interoperability will undoubtedly remain a work in progress for years to come, but widespread adoption of key frameworks shows that meaningful, industry-wide change is occurring.

Jill Hughes has covered health tech news since 2021.