Interoperability in Health Information Exchange

Moving beyond the PDF for sharing health information

Interoperability in Health Information Exchange
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Interoperability is the ability of systems and organizations to work together. In the context of health care, interoperability refers to the ability of health information systems (e.g. electronic health records [EHRs], patient registries) to connect with other systems to share, interpret, and present clinical data in such a way that the users can understand the data. Another way of thinking about interoperability is that it allows health information to follow the patient anywhere in the health care system.

The supposition is that full interoperability in health information exchange (HIE) improves the safety, quality, efficiency, and cost of health care by facilitating communication between patients, their health care providers, and public health entities.

Note that HIE is necessary but not sufficient for full interoperability. Just because two systems exchange information doesn’t mean that they have achieved full interoperability. The extent to which HIE achieves interoperability will influence the perceived value among clinicians and patients. Rather than an all-or-nothing proposition, interoperability can be achieved at varying levels:

Foundational interoperability, the most basic level, simply allows health information exchange from one information system to another, but does not require the ability for the receiving system to interpret the data.

Example: A primary care physician (PCP) diagnoses a patient with chronic kidney disease and refers the patient to a nephrologist for further evaluation and treatment.

The PCP sends a PDF of the patient’s lab results to the nephrologist’s office via secure electronic messaging. An assistant at the nephrologist’s office can manually enter the information from the PDF, or may have option of uploading the PDF into the EHR. In this instance of foundational interoperability, health information was exchanged, but the receiving system (nephrologist’s EHR) cannot interpret the data in any way.

Structural interoperability, an intermediate level, defines the structure or format of data exchange to enable uniform movement of health care data from one information system to another. The clinical or operational purpose and meaning of the data is preserved in the exchange process.

Example: The PCP sends the lab data to the nephrologist’s EHR using a messaging standard which labels the information as “Lab Results”. The nephrologist’s EHR automatically deposits the information in the Lab Results section of the patient’s record. This is structural interoperability because the receiving system (nephrologist’s EHR) correctly identifies the type of incoming information.

Semantic interoperability, the highest level, is the ability of participating information systems to automatically interpret, organize, and use the exchanged information. Semantic interoperability requires standardized structuring and codification of data, such that data can be exchanged meaningfully and accurately between information systems used by different health care facilities or made by different vendors.

This level of interoperability allows for data exchange which is capable of supporting clinical decision support, care coordination, public health reporting, and research.

Example: Although they are made by different vendors, the EHRs of the PCP and the nephrologist view the lab results in the same way. The results are fully integrated into both systems. When the nephrologist orders another set of labs to monitor the patient’s kidney disease, the EHR organizes the new results and old results into comparison tables and flow charts.


Fridsma D. Interoperability vs Health Information Exchange: Setting the Record Straight. Accessed on June 11, 2014.

Healthcare Information and Management Systems Society. What is Interoperability? Accessed on June 8, 2014.

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