An Interoperability Moonshot Proposal

Background: 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. Objectives: 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. Methods: 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. Results: 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. Conclusion: 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.