Why It Matters
Digital health information interoperability in the United States is a long-term initiative spanning multiple decades, but many obstacles still remain, according to a new Congressional Research Service (CRS) report that covers the work of the Office of the National Coordinator for Health Information Technology (ONC) and the Centers for Medicare & Medicaid Services (CMS). The report identifies four specific barriers: uneven adoption of health IT; information blocking; gaps in the Trusted Exchange Framework and Common Agreement (TEFCA); and governance that lags behind technological change.
A proposed rule known as HTI-5, published Dec. 29, 2025, would remove 34 of the 60 existing certification criteria and revise seven others, drawing mixed reactions from stakeholders who support burden reduction but worry about losing privacy, security, and artificial intelligence transparency requirements. For Congress, the report frames interoperability as a policy problem requiring ongoing oversight rather than a single legislative fix, offering options ranging from targeted funding and new mandates to allowing ONC to continue existing efforts.
The Big Picture
At least five laws and 18 regulations, either proposed or final, have shaped the current framework, beginning with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and running through the 21st Century Cures Act (P.L. 114-255), which prohibited information blocking and authorized TEFCA.
Electronic health record (EHR) adoption has reached near-universal levels in hospitals, with 100 percent of nonfederal acute care hospitals reporting certified EHR use in both 2022 and 2024, and 91 percent of office-based physicians using a certified system in 2024. Gaps persist in behavioral health, where only 19 percent of surveyed facilities reported participating in a health information exchange (HIE), and in public health, where health information organizations cited public health agencies' lack of funding and inability to receive or process messages as major barriers to connectivity.
On information blocking, ONC received 2,389 portal submissions since April 2021, of which 2,279 appeared to be possible claims, with most originating from patients and most concerning health care providers. The report notes that ONC currently lacks authority to issue binding advisory opinions on whether particular scenarios constitute information blocking, and that only Congress can grant that authority.
TEFCA, the voluntary network-of-networks that went live in December 2023, had grown to 11 designated qualified health information networks and more than 21,000 live organizations, with HHS announcing in June that more than 1 billion records had been exchanged. The report, citing an Office of the National Coordinator for Health IT blog post, identifies trust rather than technology as the central obstacle for the Trusted Exchange Framework and Common Agreement (TEFCA), and it gives Epic's January lawsuit against Health Gorilla as an example.
The Bottom Line
The report describes HTI-5 as a deregulatory proposal to remove 34 of the 60 certification criteria; describes the Health Tech Ecosystem as a voluntary, industry-alignment approach; and documents persistent adoption and trust barriers, including lower health information exchange participation among behavioral health facilities; barriers for small, rural, and independent providers; and public health agencies' connectivity challenges.
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