ELECTRONIC 

HEALTH RECORDS

Nonfederal Efforts to 

Help Achieve Health 

Information 

Interoperability

Report to Congressional Requesters

September 2015

GAO-15-817

United States Government Accountability Office
Highlights of GAO-15-817, a report to 

congressional requesters

September 2015

ELECTRONIC HEALTH RECORDS

Nonfederal Efforts to Help Achieve Health Information 

Interoperability

Why GAO Did This Study

EHR interoperability is viewed by 

many health care stakeholders as a 

necessary step toward improving 

health care. However, interoperability 

has remained limited. Although 

the federal government plays a key 

role in guiding movement toward 

interoperability, many of the actions 

are to be completed by nonfederal

stakeholders.

GAO was asked to review the status 

of efforts by entities other than the 

federal government to develop 

infrastructure that could lead to 

nationwide interoperability of health 

information. This report describes the 

(1) characteristics of selected 

nonfederal initiatives intended to 

facilitate EHR interoperability, and 

(2) key challenges related to EHR 

interoperability and the extent to which 

selected nonfederal initiatives are 

addressing these challenges. GAO 

interviewed representatives from 

18 selected nonfederal initiatives that 

were frequently mentioned by 

stakeholders GAO interviewed, 

and reflected a range of approaches. 

GAO reviewed documents from these 

initiatives as well as other published 

research.

What GAO Found

Representatives from the 18 nonfederal initiatives GAO reviewed described a 

variety of efforts they are undertaking to achieve or facilitate electronic health 

record (EHR) interoperability, but most of these initiatives remain works in 

progress. EHR interoperability is the ability of systems to exchange electronic 

health information with other systems and process the information without special 

effort by the user, such as a health care provider. These initiatives’ efforts include 

creating guidance related to health data standards, encouraging the adoption of 

certain health data standards or policies that facilitate interoperability, and 

operating networks that connect EHR systems to enable interoperability. The 

initiatives varied in a number of other ways, including the types of electronic 

systems the initiatives are working to make interoperable, the cost of their 

products or services, the geographic area served, patient use of the products or 

services, and their organizational structures. For example, GAO found that while 

some initiatives are making their products or services available at no cost, others 

are charging a fee for their products or services based on the type of entity using 

the product or service (e.g., individual physician or hospital) or the amount of 

data exchanged. Similarly, over half of the initiatives were using varying 

approaches to facilitate patient access to and control over their health 

information. The majority of the initiatives GAO selected are still in the process of 

developing, or encouraging others to adopt, their products or services. Most of 

the initiatives’ products or services were not widely available at the time of GAO’s 

review, but initiative representatives anticipated greater availability of their 

products or services in the next 2 years.

Stakeholders and initiative representatives GAO interviewed described five key 

challenges to achieving EHR interoperability, which are consistent with 

challenges described in past GAO work. Specifically, the challenges they 

described are (1) insufficiencies in health data standards, (2) variation in state 

privacy rules, (3) accurately matching patients’ health records, (4) costs 

associated with interoperability, and (5) the need for governance and trust among 

entities, such as agreements to facilitate the sharing of information among all 

participants in an initiative. Representatives from the 18 initiatives GAO reviewed 

said they are working to address these key challenges using different 

approaches. Each key challenge is in the process of being addressed by some 

initiatives. To move interoperability forward, initiative representatives noted, 

among other issues, that providers need to see an EHR system as a valuable 

tool for improving clinical care.

The Department of Health and Human Services provided technical comments on 

a draft of this report, which GAO incorporated as appropriate.

View GAO-15-817. For more information, 

contact Linda Kohn at (202) 512-7114 or 

kohnl@gao.gov.

United States Government Accountability Office
Letter 1

Background 4

Initiatives Described a Variety of Approaches for Addressing 

Interoperability and Are Generally Works in Progress 7

Stakeholders and Initiative Representatives Described Five Key 

Challenges to EHR Interoperability, Efforts to Address These 

Challenges, and Other Barriers 11

Agency Comments 21

Appendix I Selected Nonfederal Initiatives GAO Reviewed 23

Appendix II GAO Contact and Staff Acknowledgments 24

Table

Table 1: Number of Selected Nonfederal Initiatives Addressing 

Key Challenges to Interoperability 15

Contents

Page i GAO-15-817 Electronic Health Record Interoperability
Abbreviations

API application program interface

C-CDA Consolidated-Clinical Document Architecture

CMS Centers for Medicare & Medicaid Services

EHR electronic health record

HHS Department of Health and Human Services

HIE health information exchange 

HIPAA Health Insurance Portability and Accountability Act

HITECH Act Health Information Technology for Economic and 

Clinical Health Act

IT information technology

ONC Office of the National Coordinator for Health 

Information Technology

PHR personal health record

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Page ii GAO-15-817 Electronic Health Record Interoperability
441 G St. N.W.

Washington, DC 20548

September 16, 2015

Congressional Requesters

Electronic health record (EHR) interoperability is viewed by many health 

care stakeholders as a necessary step toward transforming health care 

into a system that can achieve goals of improved quality, efficiency, and 

patient safety. EHR interoperability refers to the ability of EHR systems to 

exchange electronic health information with other systems and process 

the information without special effort on the part of the user, such as a 

health care provider.1 When EHR systems are interoperable, information 

can be exchanged—sent from one provider to another—and then 

seamlessly integrated into the receiving provider’s EHR system, allowing 

the provider to use that health information to inform clinical care.

The Department of Health and Human Services’ (HHS) Office of the 

National Coordinator for Health Information Technology (ONC) is charged 

with promoting the adoption and use of health information technology by 

the Health Information Technology for Economic and Clinical Health 

(HITECH) Act, part of the American Recovery and Reinvestment Act.2

ONC has stated that EHR interoperability is key to its vision of enabling 

every individual and his or her health care providers to access the health 

information they need in a useful electronic format when and how they 

need it.3 Although ONC has reported nationwide progress on the extent to 

which providers can exchange health information among different data 

systems and organizations, it has also reported that interoperability 

remains limited due to, among other things, electronic health information 

not being sufficiently structured or standardized, a lack of financial 

1

Department of Health and Human Services, Office of the National Coordinator for Health 

Information Technology, Connecting Health and Care for the Nation: A Shared Nationwide 

Interoperability Roadmap (DRAFT Ver. 1.0) (January 2015). The Office of the National 

Coordinator for Health Information Technology plans to release the final Interoperability 

Roadmap in fall 2015.

2

Pub. L. No. 111-5, § 13101, 123 Stat. 115, 230 (Feb. 17, 2009).

3

Department of Health and Human Services, Office of the National Coordinator for Health 

Information Technology, Federal Health IT Strategic Plan, 2015-2020. (December 2014). 

For more information, see http://www.healthit.gov/policy-researchers-implementers/healthit-strategic-planning.

Letter

Page 1 GAO-15-817 Electronic Health Record Interoperability

 
motives, and misinterpretation of existing laws governing the sharing of 

health information.4

In its January 2015 draft “Interoperability Roadmap,” ONC identifies 

critical actions for public and private sector stakeholders to take to enable 

nationwide interoperability of electronic health information in the near 

term.5 Although ONC plays a key role in convening stakeholders and 

guiding movement toward interoperability, many of these actions are 

slated for completion by public and private stakeholders.

You asked that we review the status of efforts by entities other than the 

federal government to develop infrastructure needed to support 

nationwide interoperability of health care information. In this report, we

1. examine the characteristics of selected nonfederal initiatives that are 

intended to facilitate EHR interoperability, and

2. describe the key challenges related to EHR interoperability and the 

extent to which selected nonfederal initiatives are addressing these 

challenges.

To examine the characteristics of selected nonfederal initiatives that are 

intended to facilitate EHR interoperability, we first identified nonfederal 

organizations that have ongoing initiatives (nonfederal initiatives) that 

facilitate interoperability by reviewing recent articles from health 

information technology (IT) news outlets and interviewing stakeholders, 

such as the College of Healthcare Information Management Executives, 

the Healthcare Information Management Systems Society, the American 

Medical Association, and Patient Privacy Rights. We defined nonfederal 

initiatives as projects or programs outside of the federal government that 

are intended to facilitate EHR interoperability related to the provision of 

clinical care (as opposed to research). Our goal was not to identify all 

interoperability initiatives, but rather to develop a list that included a 

variety of initiatives working to facilitate EHR interoperability. We obtained 

4

Department of Health and Human Services, Office of the National Coordinator for Health 

Information Technology, Report to Congress: Update on the Adoption of Health 

Information Technology and Related Efforts to Facilitate the Electronic Use and Exchange 

of Health Information (October 2014); and Connecting Health and Care for the Nation

(January 2015).

5

Department of Health and Human Services, Office of the National Coordinator for Health 

Information Technology, Connecting Health and Care for the Nation (January 2015).

Page 2 GAO-15-817 Electronic Health Record Interoperability

 
feedback from ONC to determine the completeness and accuracy of our 

list and then judgmentally selected initiatives for our review. From our 

initial list of 39 initiatives, we selected 18 for review that were frequently 

mentioned by stakeholders we interviewed, and reflected a range of 

approaches. We interviewed representatives from these 18 initiatives to 

obtain detailed information about each initiative, including information 

about each initiative’s governance structure, funding, product 

development status, timeline, and extent to which the initiative will enable 

interoperability (e.g., among different providers and types of health 

information to be made interoperable). (See appendix I for a list of these 

initiatives.)

To describe the key challenges related to EHR interoperability and the 

extent to which selected nonfederal initiatives are addressing these 

challenges, we first identified key challenges by reviewing our 2014 report 

and interviewing stakeholders to determine the most frequently cited key 

challenges to achieving EHR interoperability.6 We confirmed identified 

challenges during interviews with representatives from the 18 initiatives 

we selected to review. We asked initiative representatives about the 

extent to which their initiatives are taking steps to address these key 

challenges, as well as any other challenges related to EHR 

interoperability. When available, we obtained relevant documentation 

from initiatives, such as bylaws, governance documents, or technical 

plans, to learn more about the extent to which the selected initiatives are 

addressing or have plans to address key challenges related to EHR 

interoperability. We also asked representatives from the 18 initiatives to 

discuss other actions that may be needed to move interoperability 

forward.

The initiatives we reviewed were selected judgmentally; therefore, any 

information gathered from our interviews cannot be generalized. 

Consequently, we are not presenting all approaches to achieving EHR 

interoperability, all the challenges related to EHR interoperability, or all 

actions needed to move EHR interoperability forward. In addition, we did 

not evaluate the initiatives’ current or planned efforts to implement 

interoperability activities or the efforts undertaken by the initiatives to 

address the challenges.

6

GAO, Electronic Health Records: HHS Strategy to Address Information Exchange 

Challenges Lacks Specific Prioritized Actions and Milestones, GAO-14-242 (Washington, 

D.C.: Mar. 24, 2014).

Page 3 GAO-15-817 Electronic Health Record Interoperability

 
We conducted this performance audit from April 2015 to September 2015 

in accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

An EHR is a digital version of a patient’s paper medical record or chart. 

EHRs ideally make information available instantly and securely to 

authorized users. An EHR can contain the medical and treatment history 

of a patient, diagnoses, medications, treatment plans, immunization 

dates, allergies, radiology images, and laboratory and test results. An 

EHR can also give a provider access to evidence-based tools for making 

decisions about a patient’s care and can automate certain workflows. 

EHR system software is typically purchased by providers (such as 

physicians, hospitals, and health systems) from vendors that develop the 

systems. When EHR systems are interoperable, information can be 

exchanged—sent from one provider to another—and then seamlessly 

integrated into the receiving provider’s EHR system, allowing the provider 

to use that health information to inform clinical care.

HHS and others view EHR system interoperability as a necessary step 

toward transforming health care into a system that can achieve goals of 

improved quality, efficiency, and patient safety. For example, use of 

interoperable EHR systems could better enable health care providers to

• view results from diagnostic procedures conducted by other providers 

to avoid duplication;

• evaluate test results and treatment outcomes over time regardless of 

where the care was provided to better understand a patient’s medical 

history;

• share a basic set of patient information with specialists during 

referrals and receive updated information after the patient’s visit with 

the specialist to improve care coordination;

• view complete medication lists to reduce the chance of duplicate 

therapy, drug interactions, medication abuse, and other adverse drug 

events; and

Background

Page 4 GAO-15-817 Electronic Health Record Interoperability
• identify important information, such as allergies or preexisting 

conditions, for unfamiliar patients during emergency treatment to 

reduce the risk of adverse events.

Health data standards are technical requirements used to, among other 

things, facilitate health information exchange and interoperability of 

systems, including EHR systems. Such standards consist of terminology 

and technical specifications that, when adopted by multiple entities, 

facilitate the exchange and interoperability of health information. Health 

data standards include, for example, standardized language for 

prescriptions and laboratory testing. Standards define how information is 

packaged and communicated from one entity to another, setting the 

language, structure, and data types required for integration between the 

systems. Standards generally have been developed by nonfederal 

standard development organizations and are accompanied by 

implementation guides, which can help ensure that standards are 

implemented uniformly. Consistent implementation of the standards by 

the vendors that build and sell EHR systems and by providers who use 

these systems is necessary for interoperability.

The Medicare and Medicaid EHR Incentive Programs are intended to 

help increase the adoption and meaningful use of EHRs by providing 

incentive payments for providers—that is, certain hospitals and health 

care professionals such as physicians—who participate in Medicare and 

Medicaid, and later imposing payment adjustments, also referred to as 

penalties, on those Medicare providers that do not meet meaningful use 

requirements for a program year.

7 Within HHS, ONC and the Centers for 

Medicare & Medicaid Services (CMS) develop the programs’ 

requirements. CMS establishes specific requirements providers must 

meet to qualify for incentive payments. Some of these requirements 

7

The HITECH Act defines “meaningful use” in relation to a user of health information 

technology that can (1) demonstrate use of certified EHR technology in a meaningful 

manner, (2) demonstrate that certified EHR technology is connected in a manner that 

provides for the electronic exchange of health information, and (3) submit information in a 

form and manner specified by HHS. For continued participation in the incentive programs, 

providers must demonstrate meaningful use and report on meaningful use measures. The 

meaningful use measures are being implemented in three progressive stages that will 

apply to different providers in different years. The Medicaid EHR program does not 

impose penalties on Medicaid providers that do not meet the Medicaid EHR program’s 

requirements by a specific date; however, if Medicaid providers also treat Medicare 

patients, they are required to meet the Medicare EHR program’s requirements from 2015 

onward to avoid penalties from the Medicare EHR program.

Page 5 GAO-15-817 Electronic Health Record Interoperability

 
include the exchange of health information, which is a component of 

interoperability. ONC identifies health data standards and technical 

specifications for EHR systems and certifies EHR systems used by 

providers in the program to help ensure that providers implement a 

system that offers a minimum level of technological capability, 

functionality, and security. In order for an EHR system to be certified, it 

must adhere to requirements related to health information exchange, 

among other capabilities.

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 

and its implementing regulations, the Privacy Rule, regulate covered 

providers’ use and disclosure of personal health information.8 Providers 

may also be subject to additional state privacy rules, which can be more 

stringent than HIPAA requirements or standards. For example, states can 

set requirements around default practices for health information 

exchange. Specifically, states that require patients to “opt-in” to health 

information exchange do not allow the sharing of health information 

unless patients affirmatively consent to share health information. States 

with “opt-out” policies around health information exchange permit, by 

default, the automatic sharing of patient health information, and patients 

must affirmatively express their preference to not have information shared 

if they do not want it exchanged.

8

Pub. L. No. 104-191, Title II, Subtitle F, 110 Stat. 1936, 2021 (Aug. 21, 1996). Additional 

privacy and security protections, and amendments to the HIPAA Privacy and Security 

Rules, were established by the HITECH Act, Pub. L. No. 111-5, Div. A, Title XIII, 123 Stat. 

115, 226-279 and Div. B, Title IV, 123 Stat. 467-496 (Feb. 17, 2009). The Privacy Rule 

was promulgated at 45 C.F.R. Parts 160 and 164 and was updated at 78 Fed. Reg. 5566 

(Jan. 25, 2013) and 79 Fed. Reg. 7290 (Feb. 6, 2014).

Page 6 GAO-15-817 Electronic Health Record Interoperability

 
The initiatives we reviewed vary in their efforts to achieve or facilitate 

interoperability, including (1) the primary products or services they offer 

(e.g., a network or guidance for implementing standards), (2) the types 

of electronic systems the initiatives are working to make interoperable, 

(3) the cost of the initiatives’ products or services, (4) the geographic 

areas served by the initiatives, (5) the extent to which initiatives facilitate 

patient access to their health information, (6) the stakeholder groups that 

are members of the initiatives, and (7) the sources of funding for the 

initiatives.

The primary products or services that the initiatives provide or are 

developing vary significantly. Among the 18 initiatives we selected, 7 are 

focused on developing technical solutions to facilitate EHR system 

interoperability, and these 7 initiatives vary with regard to the specific 

technical issue or issues they address. For example, representatives from 

these 7 initiatives said that they are addressing EHR system 

interoperability by releasing guidance intended to facilitate the uniform 

implementation of standards for EHR and other health IT systems; 

encouraging the adoption and implementation of certain standards; or 

providing services for vendors to test the extent to which the EHR 

systems they sell can interoperate with other products, such as other 

EHR systems or other health IT products, including medical devices.

Five of the initiatives we selected focus on relatively less technical 

products or services to facilitate EHR interoperability. Specifically, these 

initiatives focus on encouraging providers or insurers to adopt certain 

policies and criteria, promoting agreements between providers to facilitate 

the exchange of health information, or developing products or services 

that enable patients to aggregate their health information from multiple 

Initiatives Described a 

Variety of Approaches 

for Addressing 

Interoperability and 

Are Generally Works 

in Progress

Selected Initiatives Vary in 

a Number of Ways, 

Including Their Products or 

Services and Membership

Primary Product or Service

Page 7 GAO-15-817 Electronic Health Record Interoperability
providers into a single personal health record (PHR) that can be shared 

with additional providers.9

The remaining 6 of the 18 initiatives we selected operate or are 

developing networks aimed at facilitating EHR interoperability by 

connecting EHR systems or providers through a technical service, 

thereby allowing the exchange of information. These 6 initiatives vary in 

terms of the components or technical issues they address in building 

these networks. Approaches taken by these 6 initiatives include 

translating between different technical standards used by different 

participants in the network (a process known as semantic normalization), 

providing patient matching capabilities to providers who participate in the 

network, and developing and maintaining connections for interoperability 

between providers or regional health information exchange (HIE) 

organizations within a state or region.10

The initiatives we reviewed vary in terms of the types of electronic 

systems they are working to make interoperable. Among the 18 initiatives 

we selected, 7 reported that they are focused on achieving interoperability 

between different EHR systems, between HIE organizations’ systems, 

or between EHR and HIE organizations’ systems.11 The remaining 

11 initiatives reported that they are focused on achieving interoperability 

not only among EHR and HIE systems, but also among a wider range of 

health IT technologies, such as PHRs or medical devices. For example, 

1 initiative is working to develop application program interfaces (API), 

which are sets of programming instructions that enable the movement of 

data between software systems, in order to achieve interoperability 

between different health IT technologies. APIs allow one system to work 

9

A PHR is an electronic application used by patients to maintain and manage their health 

information in a private, secure, and confidential environment.

10Data elements contained in EHRs may be stored using different units or code sets. With 

semantic normalization, data elements are translated, or normalized, into uniform 

terminology. This can allow such information to be interoperable between different EHR 

systems.

11An HIE organization can serve as a key facilitator of exchange and interoperability by 

providing for data connections among various entities involved in clinical care, such as 

laboratories, public health departments, hospitals, and physicians. Specifically, providers 

request and receive information about patients from other providers’ records, such as 

medication lists, laboratory results, or previous diagnoses and hospitalizations, through 

HIE organizations that enable the flow of information between unaffiliated providers.

Types of Electronic Systems

Page 8 GAO-15-817 Electronic Health Record Interoperability

 
with the information provided from another system. Another initiative is 

focused on the development of interoperable applications for accessing 

health information stored in different health IT technologies, such as EHR 

systems.

Some of the initiatives we reviewed offer or will offer their products or 

services for free, while other initiatives charge or plan on charging fees for 

these products and services. Representatives from 8 of the 18 initiatives 

stated that their final products or services would be made publicly 

available at no charge. For example, representatives from several 

initiatives we reviewed that are focused on standards to facilitate 

interoperability of health information stated that they intend to make their 

guidance or instructions for implementing standards freely available to 

anyone who wants to incorporate them into a health IT product or service. 

In contrast, representatives from the remaining 10 of the 18 initiatives 

said that they are, or will be, charging fees for their products or services 

or are undecided about whether they will charge for their products or 

services once they are available. For example, 5 initiatives that operate 

networks to facilitate interoperability charge a fee, either to providers who 

use the network to exchange health information with other providers or 

vendors that want to use the network to make their EHR products 

interoperable. According to initiative representatives, their fees are 

adjusted based on factors that include the type of participant (e.g., 

individual physician, lab, or hospital) or the amount of data exchanged 

through the network.

Most of the initiatives we reviewed are national in scope, while a few are 

regional or focused on a handful of states. Representatives from 14 of the 

initiatives we selected said that they intend for their products or services 

to be available nationwide, and 5 where actively providing their services 

nationwide at the time of our review. The other 4 initiatives, all associated 

with HIE organizations, serve a particular state or multi-state region. 

Representatives from two of these HIE organizations stated that they are 

exploring connecting with HIE organizations in other states in order to 

increase their geographic coverage.

The initiatives we selected vary in the extent to which they facilitate 

patients’ access to their health information. Representatives from 11 of 

the 18 initiatives we selected identified ways in which their initiatives were

working to facilitate patients’ access to or control of their health 

Cost of the Primary Product or 

Service

Geographic Coverage

Potential Patient Role

Page 9 GAO-15-817 Electronic Health Record Interoperability
information. For example, 2 initiatives are specifically focused on patientmediated exchange as a way to facilitate interoperability.12 Both aim to 

develop products that will allow patients to use an application or PHR to 

control the sharing of health data with providers. Other initiatives are 

addressing issues related to patient consent for sharing health 

information among providers, establishing PHRs, sharing patientgenerated health information—including information that is stored on 

mobile devices—with other health IT systems (such as EHRs), and 

making all of this information interoperable.

The initiatives we selected vary with regard to the stakeholders that are 

members of the initiative. Among the 18 initiatives, representatives of 13 

said they have three or more stakeholder groups represented in their 

membership, and representatives of the remaining 5 said they had only 

one or two stakeholder groups represented. The types of stakeholders 

include a range of different groups, such as health IT vendors (including 

EHR vendors), health systems, providers (including physicians and 

hospitals), state or federal agencies, and professional associations. The 

most frequently included stakeholder groups are health IT vendors, health 

care providers, and health systems, with more than half of the initiatives 

including at least one of these three stakeholder groups as members.

Representatives from the 18 initiatives, of which 17 were not-for-profit 

efforts or part of not-for-profit organizations, cited a variety of funding 

sources for their initiatives, including grants from private organizations, 

membership fees, fees paid to utilize a network’s services, charitable 

donations, or fees paid for certain educational or technical services. 

Representatives from 8 of the initiatives said they have more than one 

source of funding. Representatives from more than half of the 18 

initiatives noted that they are examining possible changes to their funding

sources in order to sustain their initiatives. These changes include 

seeking state funding, pursuing grant funding, instituting membership 

fees, or revisiting their fee structures to accommodate different member 

types.

12Patient-mediated exchange enables patients to aggregate their own health information 

and share that information with other providers.

Membership

Funding Sources

Page 10 GAO-15-817 Electronic Health Record Interoperability

 
The majority of the initiatives we selected are works in progress, meaning 

that they are relatively new and therefore still in the process of 

developing, or encouraging others to adopt, their products or services. Of 

the 18 initiatives we selected, 10 began after January 2013. 

Representatives from 6 of the initiatives said that their primary products or 

services were available in some areas or available on a limited scale; 

however, according to the representatives, none of their products or 

services were widely available or widely used at the time of our review. 

For example, representatives from the 4 initiatives associated with HIE 

organizations said that they are actively facilitating interoperability, but 

this interoperability is confined to a single state or region. The 2 other 

initiatives have products available, but according to representatives, the 

initiatives are in the very early stages of deploying those products and 

anticipate that use of their products will increase by 2016. 

Representatives from 7 of the initiatives stated that their products or 

services are currently being developed and would not be available until 

the end of 2015 or sometime in 2016.

Stakeholders and initiative representatives we interviewed described five 

key challenges to EHR interoperability, and initiative representatives 

described how they are working to address these challenges using 

different approaches. Initiative representatives also identified other issues 

beyond the scope of their initiatives that they say need to be addressed in 

order to move nationwide EHR interoperability forward.

Most of the Selected 

Interoperability Initiatives 

Are Relatively New and 

Still Undergoing 

Development

Stakeholders and 

Initiative

Representatives 

Described Five Key 

Challenges to EHR 

Interoperability, 

Efforts to Address 

These Challenges, 

and Other Barriers

Page 11 GAO-15-817 Electronic Health Record Interoperability
Stakeholders and representatives from the selected EHR initiatives 

described five key challenges to achieving EHR interoperability: 

(1) insufficiencies in standards for EHR interoperability, (2) variation 

in state privacy rules, (3) accurately matching patients’ health records, 

(4) costs associated with interoperability, and (5) need for governance 

and trust among entities.13

While standards for electronically exchanging information among EHR 

systems exist, stakeholders and initiative representatives said that these 

standards are not sufficient for achieving EHR interoperability. This 

challenge stems from the fact that some standards are not specific 

enough and, as a result, the systems that implement these standards 

may not be interoperable. According to some stakeholders, some 

standards allow EHR systems to use different formats and terminology 

when exchanging data.14 However, this resulting variability prevents the 

receiving system from processing the information and properly integrating 

it into the patient record; in other words, the systems are not 

interoperable. Information that is electronically exchanged from one 

provider to another must adhere to the same standards, and these 

standards must be implemented uniformly, in order for the information to 

be interpreted and used in EHRs, thereby enabling interoperability.

Stakeholders and initiative representatives said that exchanging health 

information with providers in other states, which is necessary for 

nationwide EHR interoperability, can be difficult. This challenge exists 

because of variations in privacy rules from state to state, especially 

variation in laws pertaining to patient consent for sharing health 

information. According to a representative from one initiative, providers in 

13See GAO-14-242. We previously identified the first four challenges as challenges to 

health information exchange, which is a necessary component of interoperability. We 

confirmed with stakeholders that these four challenges are also challenges for achieving 

EHR interoperability, and stakeholders identified the fifth challenge.

14For example, ONC reports in its Draft Interoperability Roadmap that much of the health 

IT industry has implemented the Consolidated-Clinical Document Architecture (C-CDA), 

which is a data format standard, according to its accompanying implementation guide. 

However, one stakeholder explained that there is significant variability in the 

implementation of this standard; some portions of the C-CDA implementation guide are 

optional to implement or do not designate specific terminology. The resulting variability 

prevents the receiving system from processing the information and properly integrating it 

into the patient record, and may prohibit the user from viewing the information. ONC 

reported in its Draft Interoperability Roadmap that more guidance on how to consistently 

implement the standard is needed in order to support interoperability.

Stakeholders and Initiative 

Representatives 

Described Five Key 

Challenges to EHR 

Interoperability

Insufficiencies in Standards for 

EHR Interoperability

Variation in State Privacy 

Rules

Page 12 GAO-15-817 Electronic Health Record Interoperability

 
opt-in states may be hesitant to exchange health information with 

providers in opt-out states if the providers lack assurance that the patients 

have explicitly consented to the exchange.

This challenge may be more pronounced when exchanging certain types 

of sensitive information, such as mental health information or HIV status, 

among providers in different states. Some states require additional patient 

consent when exchanging such information.15 A representative from one 

initiative explained that current digital methods for exchange do not 

provide assurance that sensitive information is protected in accordance 

with privacy rules. According to this initiative representative, the sensitive 

information that is subject to more stringent privacy rules could be 

inadvertently aggregated with other health information and exchanged 

without the patient’s consent, thereby violating privacy rules. 

Representatives from one initiative noted that they specifically do not 

include any mental health information in electronic health information 

exchange, even with patient consent, because of concerns about 

inadvertently violating privacy rules.

Stakeholders and initiative representatives said that another key 

challenge to EHR interoperability is accurately matching patients’ health 

records that are stored in different systems.16 This challenge exists 

because many EHR systems use demographic information, such as a 

patient’s name and date of birth, to match different health records for a 

given patient held by different providers. As we previously reported, 

demographic variables do not always yield accurate results because, for 

example, there could be more than one patient with the same 

information.17 In addition, providers may not collect and use the same 

demographic variables for matching. For example, one initiative 

representative explained that a recent effort to achieve interoperability 

with another organization stalled because the other organization relies on 

15Department of Health and Human Services, Office of the National Coordinator for Health 

Information Technology, Connecting Health and Care for the Nation (January 2015).

16When a patient’s electronic health information is sent from one system to another, the 

receiving system must identify which patient the information corresponds to and link the 

new information to the patient’s record that is already in the system. If this matching is 

accurate, the provider can use the additional information to inform his or her care of the 

patient.

17GAO-14-242.

Accurately Matching Patients’ 

Health Records

Page 13 GAO-15-817 Electronic Health Record Interoperability

 
a patient’s social security number for patient matching, but the initiative 

does not collect social security numbers for its patients. In addition, some 

methods to match records for the same patient across providers can fail 

because of differences across EHR systems in data formats or because 

of missing data from or inaccurate data in some health records.

Stakeholders and initiative representatives said that the costs associated 

with achieving interoperability can be prohibitive for providers. This 

challenge exists in part because of the high cost of EHR customization 

and legal fees associated with interoperability. One stakeholder said that 

many EHR systems require multiple customized interfaces—which are 

specially designed connections to other health IT systems—in order to 

facilitate interoperability with other providers and organizations. The costs 

associated with these customized interfaces are typically paid by the EHR 

buyers (i.e., providers). Representatives from some initiatives added that 

the legal fees associated with establishing EHR interoperability can also 

be significant. For example, as the next section describes, certain 

agreements may need to be established as a precondition to 

interoperability.

Stakeholders and initiative representatives said that it can be challenging 

to establish the governance and trust among entities that are needed to 

achieve interoperability. These governance practices can include 

organizational policies related to privacy, information security, data use, 

technical standards, and other issues that affect the exchange of 

information across organizational boundaries. One stakeholder noted that 

it is important to establish agreements to ensure that entities share 

information openly with all other participants in a network. However, 

representatives from one initiative noted that there is some risk that the 

various agreements developed by different EHR initiatives could result in 

conflicting organizational policies. For example, the representative 

explained that participants in one initiative cannot participate in another 

initiative because the initiatives’ organizational privacy policies do not 

align.

Representatives from all 18 of the initiatives we reviewed said they are 

working to address these key challenges using different approaches (see 

table 1).

Costs Associated with 

Interoperability

Need for Governance and 

Trust among Entities

Each Key Interoperability 

Challenge Is in the 

Process of Being 

Addressed by at Least 

Some Initiatives

Page 14 GAO-15-817 Electronic Health Record Interoperability
Table 1: Number of Selected Nonfederal Initiatives Addressing Key Challenges to 

Interoperability

Standards Privacy

Patient 

matching Cost

Governance 

and trust

Working to address 15 11 13 16 11

Not addressing 3 7 5 2 7

Source: GAO analysis of information provided by selected nonfederal initiatives. | GAO-15-817

Fifteen of the 18 initiatives are working to address insufficient standards 

needed to achieve EHR interoperability.18 Representatives from 7 of the 

15 initiatives told us that they are developing instructions for implementing 

standards in ways that enhance interoperability. For example, 1 initiative 

provides precise definitions of how different standards can be 

implemented to meet specific clinical needs, such as locating information 

about a patient that is contained in other organizations’ EHR systems. 

This initiative also provides an opportunity for vendors to test that they 

have successfully incorporated these instructions into their products. Four 

of these 7 initiatives are working to develop instructions for implementing 

existing standards, and 3 are working to develop instructions for 

implementing a new standard that representatives said will improve 

systems’ ability to interoperate.

Representatives from 8 of the 15 initiatives told us that they require 

organizations to adopt common technical requirements as a condition of 

participation in the initiative. For example, representatives from 1 initiative 

said that it requires participants to adopt specific implementations of 

standards that enable functions like sharing health care information 

between entities. Representatives from 5 of the 8 initiatives told us that 

they also require participants to test their systems to confirm that the 

systems are able to interoperate with the systems of other initiative 

participants. For example, 1 initiative provides an online testing tool that 

vendors and providers must use to assess and demonstrate 

interoperability before joining the initiative. In addition to requiring 

agreement on technical requirements, 2 of the 8 initiatives said that they 

provide semantic normalization—that is, translation of data between 

different formats and terminology—in order to accommodate variation 

between organizations exchanging information and enable 

18Representatives from two of the three initiatives that are not addressing the standards 

challenge noted that many other initiatives are working to address this challenge.

Insufficiencies in Standards for 

EHR Interoperability

Page 15 GAO-15-817 Electronic Health Record Interoperability

 
interoperability. One initiative representative predicted that there will 

always be a need for some semantic normalization as part of 

interoperability because it is unlikely that all organizations will adopt the 

same standards in exactly the same way.

Representatives from initiatives expressed differing opinions on additional 

actions that are needed to fully address the challenge of insufficient 

standards, including the role of the federal government in addressing the 

issue. Representatives from three initiatives said that there is a need for 

federal leadership on standards and their implementation. Conversely, 

representatives from two initiatives said that current federal work on 

standards duplicates existing private sector efforts, and representatives 

from a third initiative expressed concern that the government is not 

flexible enough to account for changing technologies and should 

therefore leave this issue to the private sector. Representatives from 

three initiatives we spoke with said that standards should be tested 

through pilots before they are incorporated into national requirements, 

and suggested that this testing of standards could be an appropriate role 

for the federal government.

Eleven of the 18 initiatives we selected are working to address the 

challenges encountered because of variation in state privacy rules.19

Representatives from 6 of these 11 initiatives said that their initiatives are 

working to improve providers’ ability to obtain and track patient consent 

and other patient preferences electronically. This is important because 

some state privacy rules require affirmative patient consent to enable 

exchange. Three of these 6 initiatives are focused on improving patients’ 

ability to document their consent to exchange and grant access to their 

personal health information. For example, 1 initiative is developing a 

framework that allows patients to document digitally whether they consent 

to information sharing and to incorporate this documentation in providers’ 

health IT systems. Another initiative is working to enable patient control of 

their information through patient-mediated exchange, which allows 

patients to aggregate their health records into a PHR and electronically 

grant providers access to these records according to the patient’s 

preferences. Three other initiatives told us that they are using or plan to 

develop technology that allows providers to share only portions of a 

19Seven initiatives are not addressing this challenge. A representative from one initiative 

noted that differences in privacy laws across states halted the initiative’s efforts to 

establish cross-state exchange of information.

Variation in State Privacy 

Rules

Page 16 GAO-15-817 Electronic Health Record Interoperability

 
patient’s health record, which would allow providers to ensure that they 

send only information that they are authorized to share.

Representatives from 5 of the 11 initiatives told us that their initiative 

incorporated specific privacy policies into agreements signed by 

participants, including policies governing patient consent and access to 

their health records. For example, 1 nationwide initiative requires 

participants to obtain affirmative consent from patients before their

information can be exchanged using the initiative’s product.

Representatives from several initiatives identified additional actions that 

are needed to fully address this challenge. Specifically, six 

representatives said that education on or federal guidance about the 

application of privacy laws and liability issues would reduce confusion and 

increase willingness to exchange information across state lines. 

Representatives from one initiative noted that the difference between 

states that require patients to affirmatively consent to sharing some or all 

of their medical information and states that do not have this requirement 

is a significant barrier to interoperability, though representatives from 

another initiative said that this difference is less of an issue if providers 

are educated in the laws of their state.

Thirteen of the 18 initiatives are working to address the challenge of 

accurately matching patients’ health records.20 Representatives from 4 of 

the 13 initiatives said that their initiatives are working to improve the 

quality of the data or types of information used for matching patients’ 

health records. For example, 2 initiatives are working to establish 

standard data formats for health IT systems, which may reduce 

differences in demographic data for the same patient, thus improving the 

accuracy of matching. Representatives from 2 other initiatives told us that 

their initiative is working to create a list of patient attributes (e.g., 

telephone number and address) that can be combined to establish a 

patient’s identity with high success and enable providers and others to 

match patient records as accurately as possible.

Representatives from 7 of the 13 initiatives told us that they require their 

participants to use a standardized method for patient matching or are 

20Representatives from three of the five initiatives that are not addressing this challenge 

noted that they expect the provider to match patients’ records through other means.

Accurately Matching Patients’ 

Health Records

Page 17 GAO-15-817 Electronic Health Record Interoperability

 
working to develop standardized methods. For example, 1 initiative 

requires that all participants incorporate the same patient-matching 

method into their EHR systems. Representatives from 2 other initiatives 

said that their initiative is working to reconcile variations in the data 

elements and formats used for patient matching by network participants, 

with the goal of adopting a single shared method among all participants. 

Representatives from another initiative told us that the initiative is working 

to develop a tool for matching patients to their records that can be 

incorporated directly into EHR systems. Notably, 2 of the initiatives that 

are working on patient-matching methods said that they rely on patients 

to confirm that the match is accurate at the site-of-care. Representatives 

from 1 of these initiatives noted that this approach may not be practical in 

circumstances or settings in which information is required immediately or 

the patient is unresponsive.

Representatives from 2 of the 13 initiatives said that they are working to 

enable patient-mediated exchange, which involves allowing patients to 

aggregate their health information in a PHR. One representative noted 

that patients are likely to notice if their PHR contains information that is 

incorrectly matched and to correct the error.

Representatives from five initiatives noted that a national patient identifier, 

which HHS identifies as currently prohibited under law, is needed to fully 

address this challenge.21

Sixteen of the 18 initiatives are working to address the challenge of the 

reported high costs associated with interoperability.22 Some of these 

initiatives are working to address this challenge using multiple 

approaches. Representatives from 10 initiatives that said they are 

addressing this challenge by reducing the need to customize EHR 

systems to connect with other systems. For example, representatives 

21HHS has stated that it is prohibited from implementing a national patient identifier and 

has referred to the Omnibus Consolidated and Emergency Supplemental Appropriations 

Act of 1999. The act prohibits HHS from using any funds to promulgate or adopt any final 

standard providing for, or providing for the assignment of, a unique health identifier for an 

individual until legislation is enacted specifically approving the standard. See Pub. L. 

No. 105-277, § 516, 112 Stat. 2681, 2681-386 (1998). 

22Representatives from the two initiatives that are not addressing this challenge said that 

the result of their initiative will ultimately reduce the cost of health care rather than the cost 

of interoperability specifically. 

Costs Associated with 

Interoperability

Page 18 GAO-15-817 Electronic Health Record Interoperability

 
from 1 initiative explained that participants must adopt standard features 

that should reduce the amount of customization needed to connect with 

other systems. Representatives from 3 initiatives explained that they give 

participants the opportunity to reduce the cost of interoperability by paying 

for only one interface to connect with all the entities participating in the 

initiative, instead of paying for individual connections to each entity. 

Officials from 3 other initiatives told us that they are focused on creating 

APIs—programming instructions that allow systems to extract data from 

other systems that adopt the same API—that they said would nearly 

eliminate the need to customize systems that adopt the API, or are 

working to leverage APIs to create applications that can be easily added 

to EHR systems to exchange and analyze interoperable data.

Representatives from 12 initiatives said that their initiatives’ products are 

or will be available at no cost or at a reasonable cost to providers or 

vendors. For example, representatives from 4 initiatives told us that the 

profiles and specifications they are developing will be available free of 

charge for vendors and providers to incorporate into EHR systems. 

Representatives from 6 other initiatives said that they are attempting to 

keep the cost of participation in the initiative reasonable. For example, 

representatives from 1 initiative said that they adjust their fees for 

different provider types to accommodate differences in the providers’ data 

exchange needs, thus increasing the likelihood that providers can afford 

to participate.

Representatives from three initiatives explained that they are working to 

address the cost issue by creating standardized legal agreements to 

govern information sharing, which can be easily adapted by initiative 

participants and reduce the need for legal services and the accompanying 

legal fees.

Eleven of the 18 initiatives are working to establish governance and trust 

among the entities that seek to exchange interoperable health 

information.23 Representatives from 7 of the 11 initiatives are fulfilling the 

need for governance and trust among entities by establishing standard 

legal agreements that their participants adopt and use to govern 

relationships within the initiative. For example, 1 initiative crafted a 

23Representatives from five of the seven initiatives that are not addressing this challenge 

said that they are not doing so because they are focused on developing technical 

capabilities and, therefore, this challenge is outside of their scope.

Need for Governance and 

Trust among Entities

Page 19 GAO-15-817 Electronic Health Record Interoperability

 
publically available agreement that includes provisions related to security 

and authentication policies, as well as a requirement that all participants 

share patient health information openly with all other participants that are 

authorized to receive this information. Another initiative has created a 

committee to evaluate specific ways that the data contained in the 

network may be used and incorporates these decisions into its 

agreement. Another initiative deliberately designed its agreement so that 

participants can also adopt existing national agreements; a representative 

from this initiative noted that if there was a situation in which their 

agreement conflicted with another initiative’s requirements, the initiative 

would work to reconcile the conflicting requirements so its participants 

could participate in both initiatives whenever possible.

Representatives from 4 of the 11 initiatives told us that they are working 

to address this challenge by fostering consensus and harmonization of 

policies and business practices across entities and organizations. For 

example, 1 initiative facilitates consensus among different stakeholders 

about methods to enable interoperability for certain uses, and releases 

the results of these discussions publically for other entities to incorporate 

into their agreements, policies, and practices.

In addition to the five challenges identified by stakeholders and initiative 

representatives, representatives identified two other issues that need to 

be addressed in order to move nationwide interoperability forward.

• EHR interoperability would move forward once providers saw a value 

in their systems becoming interoperable. Six initiative representatives 

said that improvements to EHR systems—such as enhancements that 

improve providers’ workflow or clinical decision-making—are needed 

to increase the extent to which an EHR system, and the information 

contained within it, is a valuable tool for health care providers. Six 

initiative representatives noted that reforms that tie payment to quality 

of care rather than number of services provided will incentivize 

sharing of information across providers to improve efficiency.

• Changes to CMS’s Medicare and Medicaid EHR Incentive Programs 

would also help move nationwide interoperability forward. While 

8 initiative representatives we spoke with told us that the EHR 

Incentive Programs have increased adoption of EHRs, 

representatives from 5 initiatives suggested pausing or stopping the 

programs. Representatives from 10 of the initiatives noted that efforts 

to meet the programs’ requirements divert resources and attention 

from other efforts to enable interoperability. For example, some 

Initiative Representatives 

Identified Other Issues 

That Need to be 

Addressed to Move 

Nationwide EHR 

Interoperability Forward

Page 20 GAO-15-817 Electronic Health Record Interoperability
initiative representatives explained that the EHR programs’ criteria 

require EHR vendors to incorporate messaging capabilities into EHR 

systems, but this capability generally does not enable interoperability 

at this time. Representatives from 10 of the initiatives said that the 

criteria currently used to certify EHR systems under the EHR 

Incentive Programs are not sufficient for achieving interoperability, 

and representatives from 3 initiatives suggested amending the criteria

to focus on testing systems’ ability to interoperate.

We provided a draft of this report to HHS for comment. HHS provided 

technical comments, which we incorporated as appropriate.

As agreed with your offices, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 30 days from the 

report date. At that time, we will send copies to the Secretary of Health 

and Human Services, the Administrator of CMS, the National Coordinator 

for Health Information Technology, appropriate congressional 

committees, and other interested parties. In addition, the report will be 

available at no charge on the GAO website at http://www.gao.gov. 

If you or your staffs have any questions about this report, please contact 

me at (202) 512-7114 or at kohnl@gao.gov. Contact points for our Office 

of Congressional Relations and Office of Public Affairs can be found on 

the last page of this report. Other major contributors to this report are 

listed in appendix II.

Linda T. Kohn

Director, Health Care

Agency Comments

Page 21 GAO-15-817 Electronic Health Record Interoperability
List of Requesters

The Honorable Lamar Alexander

Chairman

Committee on Health, Education, Labor, and Pensions

United States Senate

The Honorable Michael Enzi

Chairman

Subcommittee on Primary Health and Retirement Security

Committee on Health, Education, Labor, and Pensions

United States Senate

The Honorable Richard Burr

United States Senate

The Honorable Pat Roberts

United States Senate

The Honorable John Thune

United States Senate

Page 22 GAO-15-817 Electronic Health Record Interoperability
Appendix I: Selected Nonfederal Initiatives 

GAO Reviewed

We identified nonfederal organizations that have ongoing initiatives that 

are working to facilitate electronic health record (EHR) interoperability. 

The 18 initiatives we selected for our work are listed below.

• Argonaut Project

• California Association of Health Information Exchanges (CAHIE)

• Carequality

• Center for Medical Interoperability (C4MI)

• CommonWell Health Alliance

• ConCert by Healthcare Information and Management Systems 

Society (HIMSS)

• eHealth Exchange

• eHealth Initiative (eHI)

• Electronic Healthcare Network Accreditation Commission (EHNAC)

• Healthbridge

• Healthcare Services Platform Consortium (HSPC)

• Identity Ecosystem Steering Group (IDESG) Healthcare Committee

• Integrating the Healthcare Enterprise (IHE) USA

• Kansas Health Information Network (KHIN)

• National Association for Trusted Exchange (NATE)

• Open ID Health Relationship Trust (HEART) Working Group

• Statewide Health Information Network of New York (SHIN-NY)

• Substitutable Medical Applications and Reusable Technologies 

(SMART) on Fast Healthcare Interoperability Resources (FHIR)

Appendix I: Selected Nonfederal Initiatives 

GAO Reviewed

Page 23 GAO-15-817 Electronic Health Record Interoperability
Appendix II: GAO Contact and Staff 

Acknowledgments

Linda Kohn, (202) 512-7114 or kohnl@gao.gov

In addition to the contact named above, Tom Conahan, Assistant 

Director; A. Elizabeth Dobrenz; Krister Friday; Monica Perez-Nelson; 

and Andrea E. Richardson made key contributions to this report.

Appendix II: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(291262) Page 24 GAO-15-817 Electronic Health Record Interoperability
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