An Interoperability Moonshot Proposal

Clinical data exchange remains fragmented and insufficient to support coordinated, safe care. Decades of technological progress, standards development, and interoperability-focused legislative and regulatory improvements have been incremental, underscoring the need for unifying initiatives to coordinate and improve operations and outcomes.

We sought to identify persistent barriers limiting clinical data interoperability. We propose a coordinated, time-bound U.S. "moonshot" initiative to create a unified canonical clinical terminology ("SuperSNOMED") and catalyze rapid refinement and streamlined adoption of Fast Healthcare Interoperability Resources (FHIR) and Implementation Guides (IGs) to accelerate safe, high-fidelity data exchange.

We synthesized insights from an expert roundtable; conducted additional expert discussions; appraised peer-reviewed published and online evidence on standards, interoperability policies, and developing regulations; and then identified barriers to interoperability implementation. We then developed recommendations for policy, legislative, and regulatory changes.

We identified five barrier domains: fragmented terminology standards and value sets; multiple overlapping data exchange standards with uneven FHIR adoption; incomplete or misaligned certification and policy incentives; variable interpretation and implementation of IGs; and insufficient funding and support for standards development. We propose a national program including three coordinated pillars: SuperSNOMED, a well-governed, rapidly maintained, canonical terminology integrating major domains and mappings; FHIR acceleration converging on a minimum set of IGs and certified legacy-data transforms during a transition window; and policy and governance for certification criteria, incentive alignment, and funding a paid expert task force to execute an ambitious 3-year plan. Certification and workforce incentives with transitional data-quality safeguards such as reconciliation-on-first-use for transformed historical data would catalyze high-impact interoperability beyond existing EHR regulatory programs, clinical information systems, and knowledge bases critical to health care.

Interoperability remains fragmented despite progress. This state-of-the-art paper is a call to action for a focused, funded, well-governed national moonshot effort to unify terminology and streamline exchange standards.