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Nationwide health information exchange networks face growing pressure to take on responsibilities that extend far beyond their original design, raising questions about whether current governance models can keep pace with the demands of modern interoperability.
Those networks are now expected to address fraud prevention, enforce information-blocking rules, protect patient privacy and expand access, often without consistent oversight or a sustainable funding structure. Bob Watson, chairman and CEO of Health Gorilla, argues the current approach is no longer viable.
"We built nationwide exchange networks to enable data movement, not to govern it at the scale they now operate," Watson said.
Watson and his organization have submitted formal recommendations to federal regulators as policymakers consider the next phase of Trusted Exchange Framework and Common Agreement (TEFCA) maturity and information-blocking enforcement.
The proposal centers on establishing a more consistent and durable governance structure for nationwide exchange. The core issue, Watson said, is that governance has lagged adoption.
"As interoperability has matured into critical infrastructure, gaps in consistent credentialing, participant accountability and transparency have become more visible," he said.
Today's federated model relies on distributed onboarding processes and uneven oversight across networks, which can create variability in how participants are vetted and monitored. That inconsistency introduces risk across multiple areas, including fraud detection, data sharing compliance and privacy safeguards.
To address those gaps, Watson is advocating for a federally overseen, industry-funded credentialing authority that would serve as a standardized entry point for participation in nationwide exchange.
The model would separate onboarding and credentialing from commercial interests, creating a more neutral framework for verifying identity, licensure and data exchange intent.
"A federally overseen, industry-funded credentialing authority would introduce a neutral, consistent front door to nationwide exchange," Watson said.
He argues that standardization would reduce variability across networks and improve trust in the system, even if it introduces modest additional costs. Those costs, he said, would be offset by improvements in efficiency and care delivery as more complete and reliable data flows across the system.
At the same time, Watson emphasized that stronger oversight must be implemented carefully to avoid unintended consequences for smaller providers.
Many rural and resource-constrained organizations rely on existing networks and may lack the infrastructure to meet more stringent requirements without support.
"Stronger oversight must be paired with proportionality," he said.
That approach would include tiered requirements, shared services and safe harbor protections for providers acting in good faith. Governance models, he added, should distinguish between intentional misuse of data and operational challenges, with clear remediation pathways before enforcement actions are taken.
Patient trust is another critical component of the proposed framework. Watson pointed to the need for scalable digital identity systems, more consistent consent models and improved transparency into how patient data is accessed and used.
"Individuals need to understand who is accessing their data and why, without slowing appropriate care," Watson said.
THE LARGER TREND
The recommendations come at a time when interoperability is increasingly viewed as foundational to care delivery rather than a supporting capability.
It's a shift driving enhanced expectations around accountability, data contribution and measurable outcomes across exchange networks.
Watson said the debate reflects a broader transition in how healthcare views interoperability.
"Interoperability has gone from 'nice to have' supplementary connectivity to interoperability as critical infrastructure," he said.
As data exchange becomes central to clinical and operational workflows, governance expectations are expanding beyond enabling access to ensuring trust, reciprocity and measurable value.
"The future of interoperability will be defined as much by accountability and outcomes as by access," said Watson.
