Complete guide to hospital interoperability in the USA — HL7 FHIR R4, TEFCA framework, USCDI v3 data set, Carequality, eHealth Exchange, API integration, and ONC interoperability rules.
The ONC Cures Act mandates information blocking prohibitions and FHIR-based API access for all certified EHRs. Non-compliance can result in penalties up to $1 million per violation. Interoperability is no longer optional — it's the law.
Interoperability Standards & Frameworks
| Standard/Framework | Purpose | Status |
|---|---|---|
| HL7 FHIR R4 | Modern API-based data exchange | Mandatory for ONC certification |
| USCDI v3 | Minimum data set for exchange | Required for ONC certification |
| TEFCA | National exchange framework | Live, voluntary (mandatory by 2027) |
| Carequality | Inter-network exchange | Active, 500K+ connected providers |
| eHealth Exchange | Federal/VA exchange | Active, connects federal agencies |
| Direct Trust | Secure email messaging | Active, used for care coordination |
| IHE profiles | Integration profiles for workflows | Widely adopted |
ONC Cures Act Requirements
- Information blocking prohibition: Cannot block or delay patient data access
- FHIR-based API: Must provide FHIR R4 API for all USCDI data elements
- Patient access: Patients must access their data via app of their choice
- Real-time exchange: Data must be available in real-time, not batched
- No special treatment: Cannot charge more for API access than other interfaces
- Bulk data export: Must support FHIR Bulk Data Access for population health
TEFCA Connection Benefits
- National exchange: Connect to any other TEFCA participant nationwide
- Single on-ramp: One connection to exchange with all networks
- Query-based exchange: Query patient records from any connected provider
- Directed exchange: Send records securely to specific recipients
- Consumer-mediated exchange: Patients can request their records be sent
- Public health reporting: Report to public health agencies via TEFCA
Frequently Asked Questions
- What is TEFCA in healthcare?
- TEFCA (Trusted Exchange Framework and Common Agreement) is the ONC's national health information exchange framework. It creates a single 'on-ramp' for health data exchange across all networks. TEFCA went live in 2024 and hospitals are expected to connect by 2027 for seamless nationwide data sharing.
- What is HL7 FHIR and why does it matter for US hospitals?
- HL7 FHIR (Fast Healthcare Interoperability Resources) is the modern healthcare data exchange standard. ONC's Cures Act mandates FHIR-based APIs for all certified EHRs. FHIR enables real-time data exchange between systems, apps, and devices — essential for interoperability and innovation.
- What is the USCDI and what data elements does it include?
- USCDI (United States Core Data for Interoperability) is the standardized set of health data classes that must be available for exchange. USCDI v3 includes 20 data classes: patient demographics, allergies, medications, problems, lab results, imaging, procedures, clinical notes, and more. All ONC-certified EHRs must support USCDI.