The average person moves more than 11 times in their lifetime. While this is rarely considered a “red flag” in the rhythm of everyday life, when those undergoing treatment for a serious illness such as cancer relocate to another state, it could very well compromise the continuity and coordination of their care. That patient has likely seen multiple specialists, undergone countless lab tests, and built a clinical history that will matter for the rest of their life. Yet the odds that all of those critical records seamlessly follow them to their new home are, unfortunately, not very high.
A major reason for this gap is our continued reliance on "geofencing" to streamline medical record retrieval. At its core, geofencing creates virtual boundaries around a defined geographic area using technologies like GPS. In healthcare, this has worked well in the past for care that is and will remain local. But as national interoperability frameworks advance, it’s becoming clear that geofencing no longer fits the moment. What once was a helpful feature has become a bug, and if we’re serious about achieving true nationwide interoperability, we need to move past it.
Stalling national interoperability efforts
Most health information networks and organizational systems, especially those focused on regions or specific states, are maintained within a geofence for speed and accuracy. However, this structure creates real challenges for patients who move to new cities or states or even snowbirds, who split their time living in different states seasonally, as well as for the providers who inherit their care. Let’s just say their health data does not seamlessly follow along with the moving boxes in the U-Haul. Geofencing assumes patients are local and will stay local, which is increasingly unrealistic, yet our data systems still put all their eggs in that single basket. And because geofencing can’t be scaled nationally, it ultimately limits the effectiveness of health information exchanges (HIEs) and undermines the broader progress we’re trying to make as a nationwide healthcare community.
High-quality healthcare is betting heavily on the success of national interoperability through initiatives like the Trusted Exchange Framework and Common Agreement (TEFCA) and the Centers for Medicare & Medicaid Services (CMS) framework. But for these efforts to deliver on their promise, the vision must include a road map that moves beyond geofencing and toward an infrastructure where patient data follows the patient wherever they go — and where nationwide exchange is the default, not the exception.
Removing barriers for better data exchange
Local and state HIEs can already plug into national patient-matching and record-locator efforts, but national HIE organizations need to step up to serve as the pipes that deliver their local reach to make access a reality anywhere a patient receives care. To achieve true patient interoperability at a national level and to move beyond the limitations of geofencing, all exchanges have a role to play.
Here are a few ways we can move the needle:
● Everyone needs to buy in. This includes all of the Qualified Health Information Networks (QHINs) and those that have ambitions to improve patient access both inside and outside geographic borders. Healthcare data moves with the patient, not geography.
● Kill the “state lines” problem. While state and regional HIEs are invaluable, we as a nation haven’t made the leap to true national interoperability due to a lack of engagement between HIEs and QHINs. With the support of TEFCA, additional policies will support pathways to participation and engagement.
● The need for a unified framework. Building a consistent national foundation through TEFCA means states and QHINs are playing by the same rules — more like a connected ecosystem and less like a patchwork that only works when all the pieces magically line up.
● Better patient matching. Ensuring patient data matches, demographically and clinically, is a must-have for interoperability, and yet today it remains a process riddled with errors due to lags between systems. A combined Master Patient Index (MPI) and Record Locator Service (RLS) are critical technologies to enable accurate data exchange along with agreement on a standard approach to matching. A lack of consistent algorithms across networks is eroding trust when our goal should be increasing it.
● Make data usable. Matching is only possible when data is organized and normalized consistently. The continued adoption of FHIR, or Fast Healthcare Interoperability Resources, is poised to help define data formats, ultimately helping different systems share data more easily and accurately based on a standard language.
● CMS/The Office of the National Coordinator for Health Information Technology to push incentives. Targeted incentives can create interest, driving momentum to help overcome the limitations of geofencing/local networks, and accelerate national interoperability. This could include everything from quality-based rewards to waivers.
If we don't solve the challenges that led to the use of geofencing, it will be difficult for us as a nation to move past its inherent value and limitations.
A unified approach for sustainable change
To say that nationwide interoperability is a marathon, not a sprint, is perhaps the understatement of the decade, but this doesn’t detract from its truth. We should be celebrating progress in private and public sectors — from the proliferation of patient access solutions to the creation of the CMS Interoperability Framework. However, now is not the time to slow down. The entire landscape dedicated to national interoperability — from policymakers to QHINs, HIEs, and technologists — must consider the usefulness and application of geofencing in their future strategies. If we’re serious about achieving nationwide interoperability, removing geographic constraints isn’t an option. If we don’t, it will be the very thing holding us back from making it over the fence to address barriers to access.
Paul L Wilder is executive director of the CommonWell Health Alliance, a nonprofit member-driven alliance and Qualified Health Information Network (QHIN).