What are the Four Levels of Interoperability in Healthcare?

Healthcare interoperability is critical for connected care clinical workflows. Interoperability enables the flow of information between systems, ensuring that information is not only sent and received but also understood and standardized. 

But true interoperability can only be achieved when all four levels of interoperability are addressed. The four levels of interoperability are:

1. Foundational Interoperability
2. Structural Interoperability
3. Semantic Interoperability
4. Organizational Interoperability

In this article, we’ll discuss the types of interoperability in healthcare, the challenges organizations may face when trying to achieve it, and real examples of successful interoperability in healthcare facilities. 

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Why Interoperability Matters in Healthcare

While interoperability is a data-driven concept, it isn’t solely an IT concern. Without interoperability, healthcare systems remain fragmented and critical data is siloed from the providers and clinical teams who need it. 

For example, a patient may visit their primary care doctor, then see a specialist, then have lab work done at a third location. Without interoperability, each of these places might have its own isolated record of care, and none of them can easily see what the others documented. 

This not only creates clinical burden and decreases operational efficiency, but can also impact patient safety. Communication failures are the most common cause of medical errors – and an estimated 67% of communication errors are related to patient handoffs. 

Interoperable systems help clinical teams function by ensuring the right information is exchanged at the right time, and in a standardized manner. The flow of information makes key data easily accessible – which is critical for clinical decision making.

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Healthcare Data Exchange Standards

In the US, healthcare organizations must adhere to The 21st Century Cures Act. The act was created in 2016 and establishes a legal framework to address the use and exchange of health data through health information technology (HIT). 

Not only is this act designed to strengthen interoperability, but it also prevents information blocking. Information blocking is any practice that interferes or prevents access to a patient’s electronic health information (EHI). 

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The Four Levels of Interoperability in Healthcare

The Healthcare Information and Management Systems Society (HIMSS) defines four levels of interoperability. All levels must be met to achieve true interoperability. 

1. Foundational Interoperability

Foundational interoperability is the ability for basic data exchange between systems. This includes sending and receiving, without interpretation. For example, sharing a lab result or imaging via a secure messaging app. 

This level establishes the essential first step toward connectivity between systems, ensuring that information can flow electronically – allowing providers to modernize and streamline communications instead of relying on fax, phone calls, or paper notes. 

The primary function of foundational interoperability is to send and receive information, but it doesn’t enable interpretation. Without higher levels of interoperability, the receiving system can’t fully understand or act on the information that was shared.

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2. Structural Interoperability

Structural interoperability standardizes data format and syntax so systems can read and organize information consistently. At this level, providers follow standards set by FHIR – Fast Healthcare Interoperability Resources, the standard for exchanging healthcare information electronically – to ensure consistency across systems. 

Providers can also use tools that offer standardized templates as a way to ensure data consistency. Standardization not only reduces manual entry and ensures data consistency, but it can also help improve real-time communication. For example, using templates to send critical patient alerts or emergency code activations. 

While structural interoperability helps standardize data, it doesn't guarantee understanding. 

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3. Semantic Interoperability

Semantic interoperability helps create shared meaning across different systems, allowing not only the exchange of information, but also the understanding of it. 

For example, one provider may record a patient’s allergy as “PCN allergy” while another system documents it as “penicillin allergy.” When that information is exchanged at the semantic level, each system should be able to interpret the data and translate it for the correct output. 

The way systems achieve semantic interoperability is by using standardized vocabularies. The most common is SNOMED CT, which provides standardized, multi-lingual medical terminology that’s used in over 80 countries. 

Other sets of overlapping vocabulary standards include:

• ICD-10-CM: The International Classification of Diseases, 10th Revision, Clinical Modification is a standardized medical coding system used to classify diseases, symptoms, and injuries. 
• LOINC: Logical Observation Identifiers Names and Codes (LOINC) is a vocabulary standard that provides universal identifiers for laboratory tests and clinical observations.
• RxNorm: Provides standardized names for clinical drugs and links its names to the drug vocabularies commonly used in pharmacy management and drug interaction software.

Semantic interoperability adds clarity to information exchange. This effectively enables clinical decision making, helps prevent duplicate tests, and can even reduce errors, according to some research.

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4. Organizational Interoperability

Organizational interoperability addresses the governance, policies, and agreements that enable data exchange across institutions. Even if systems can technically exchange and understand data, organizational factors determine whether and how that exchange actually happens.

To maintain interoperability, organizations must follow certain health information exchange (HIE) frameworks. HIEs enable the electronic exchange of health care information across organizations within a region, community, or hospital system.

The most common HIE framework is the Trusted Exchange Framework and Common Agreement (TEFCA). Part of the 21st Century Cures Act, TEFCA is the governance framework designed to enable nationwide electronic health information exchange to ensure that HINs, health care providers, health plans, and individuals have secure access to the data. 

In Canada, organizations can follow the Pan-Canadian Health Data Content Framework. Developed by the Canadian Institute for Health Information (CIHI) and coordinated by Canada Health Infoway, this framework standardizes models and definitions for health data. 

Establishing organizational interoperability builds trust with patients, establishes credibility within the healthcare network, ensures compliance, and supports a complete system-to-system collaboration. 

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Benefits of Achieving Higher Interoperability in Healthcare

There are numerous benefits to establishing higher interoperability using clinical communication platforms.

1. Improved patient safety and reduced errors
2. Faster clinical decision-making and care coordination
3. Less administrative burden and clinician frustration
4. Compliance with regulations

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Improved patient safety and reduced errors

When systems truly communicate, providers have all of the information needed for comprehensive decision-making. This is critical to reduce errors and effectively improve patient safety. 

For example, when physicians see complete medication histories before prescribing, they may catch dangerous drug interactions that would otherwise slip through. In another instance, duplicate testing may be avoided because providers can see labs already performed elsewhere, sparing patients unnecessary procedures and systems unnecessary cost. 

Using an interoperable clinical communications platform can make this easier by syncing the most critical tools of clinical workflows. 

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Faster clinical decision-making and care coordination

Without interoperability, clinical coordination depends on phone tag, faxes, and manual information requests that can take hours, or even days. 

Interoperable systems enable near-instantaneous communication. For example, a consultation request sent via secure messaging can include all relevant patient information, lab results and images. The specialist then receives a complete clinical picture and can immediately respond with recommendations that flow back into the primary care physician's workflow. As another example, code team activations through a bedside alarm can flow through a communication platform to instantly assemble the right people, while emergency decisions get made with complete context rather than treating patients in an information vacuum. 

This increased visibility and real-time communication helps teams coordinate care and reduces communication gaps. 

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Less administrative burden and clinician frustration

A 2016 study found that physicians spend 30 minutes of a four-hour period searching for paperwork or equipment. This type of task takes away the time that should be spent on patient care. Not to mention, administrative burden is one of primary contributors to burnout among healthcare professionals. 

When clinicians have access to the right information at the right time, the cognitive burden of piecing together fragmented information across multiple systems lessens. This can also help reduce communication fatigue, which is often the result of data overload and context-switching. 

Instead of spending critical time searching for records or looking for the right provider to contact for a consult, providers can focus their resources on patient care. 

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Compliance with regulations

When healthcare organizations use a HIPAA-compliant, interoperable clinical platform, providers can not only focus on coordinating patient care, but also have the guidance needed to share information in a compliant manner. 

Additionally, audits and regulatory inquiries can get resolved quickly when complete documentation is retrievable. Privacy and security compliance also improves because authorized access is controlled and auditable rather than taking place via insecure faxes or non-compliant messaging apps. All of this combined helps organizations avoid penalties. 

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Challenges Healthcare Organizations Face with Interoperability

Achieving complete interoperability remains challenging for many healthcare organizations. While foundational interoperability is often the easiest level to achieve, clinical teams may face the following challenges:

1. Technical challenges
2. Semantic challenges
3. Organizational challenges
4. Resource constraints

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Technical challenges

Many hospitals still rely on legacy infrastructure that can't easily interface with modern applications. Even when standards like HL7 FHIR exist, inconsistent implementation creates a patchwork where systems speak the same language but with different dialects. 

Network security requirements add another layer of complexity by protecting patient data while enabling seamless exchange requires sophisticated architecture. API integration can also be a challenge with authentication protocols, and managing the sheer volume of data exchange points.

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Semantic challenges

One of the biggest challenges is semantic interoperability. Clinical terminologies like SNOMED CT, ICD-10, LOINC, and RxNorm often overlap but don't map perfectly to each other, creating inconsistent use of vocabularies. One hospital's "moderate pain" could be another's "severe pain" based on their local scales. 

Medication lists can become an even bigger obstacle when drug names, dosages, and formulations vary across systems. The context around data – why a test was ordered, what the physician was thinking – often gets lost in translation, leaving receiving providers with numbers but not understanding.

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Organizational challenges

There are several ways that organizations can stand in their own way when it comes to implementing interoperability within their facilities. A few examples include: 

• Department or institution silos: Different departments within the same hospital often operate as silos, and coordinating across institutions is even more challenging. Without policies in place, governance becomes political – who owns the data, who decides on standards, and who pays for what? Trust between competing healthcare systems is limited as sharing data with competitors feels counterintuitive.
• Leadership buy-in: Even after facility and clinical leaders are on board, there’s also the potential for strategic priorities to shift. This results in interoperability initiatives losing champions.
• Aligning stakeholders: Getting all stakeholders – IT, clinical staff, administration, legal, compliance – aligned on priorities can also be a challenge. 
• Clinical team adoption: Busy clinical teams may be hesitant to learn and implement a new system without change management. 

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Resource constraints

Interoperability initiatives may require significant upfront investment with unclear ROI timelines. For small and rural hospitals, modernizing their infrastructure or hiring specialized interoperability experts is even more of an expensive undertaking. Organizations must balance interoperability spending against immediate clinical needs, facility improvements, and other pressing demands. 

Additionally, the regulatory compliance burden – HIPAA, information blocking rules, state privacy laws – requires dedicated legal and compliance resources. Even when money is available, project timelines may stretch, and the technology landscape shifts before implementations are complete. One way to address this is by selecting a technology solution with built-in interoperability. This ensures your organization is compliant while also getting the most out of multiple functions. 

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Real-World Examples of Interoperability in Action

By using interoperable platforms like Hypercare, hospitals can improve critical communication processes and systems such as code activations, integrated secure messaging, and on-call scheduling. 

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Automated and Optimized Emergency Code Activations 

Real-time data exchange is critical for timely emergency response activations including Code STEMI, Code Blue, Code Stroke, Life and Limb situations, and other urgent scenarios.

Royal Victoria Regional Health Centre (RVH), a leading regional hospital in Ontario, relied on a traditional switchboard system to manually page interventional cardiology teams when a patient presented with a STEMI. This involved switchboard operators having to locate the correct on-call providers, page them, and wait for a response, a process that ultimately created delays. Additionally, securely transmitting ECGs to interventional cardiologists was difficult, impeding rapid decision-making.

To address these challenges, RVH partnered with Hypercare to implement a real-time, automated emergency response system. The one-click activation instantly notifies the entire STEMI team, and overrides silent and do-not-disturb settings to ensure immediate response, which reduces emergency code activation time. Additionally, the ability to share ECGs and patient details in real time has enabled faster, more informed decisions and interventions. The entire team can communicate amongst themselves as the patient and the situation involves, ensuring situational awareness.

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Replacing Pagers and Switchboards

Health Sciences North (HSN), a regional hospital for Northeastern Ontario, used Hypercare to replace its fragmented communication system – legacy pagers and an external switchboard service – with a unified communication platform.

Not only did they want to move away from traditional paging and answering services, but HSN also sought to improve communication and collaboration amongst providers by implementing secure messaging and consolidating disparate on-call schedules onto a central digital platform. 

The transition from foundational interoperability to structural interoperability resulted in significant efficiency gains for the hospital. 

Within one month, 70% of eligible users adopted the system, over 45,000 secure messages were exchanged, and 46 on-call schedules were consolidated into the platform. This ultimately resulted in a 50% drop in switchboard call volumes one year after implementation.

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Faster Code Activation

A unified communications platform that enables structural and semantic interoperability can directly improve emergency response and reduce risk, as demonstrated by Mile Bluff Medical Center. 

Mile Bluff is a small hospital in rural Wisconsin that operates with lean teams. Its communication systems – which included manual calls to the switchboard, on-call schedules that were buried on the intranet, and a lack of secure messaging – were fragmented. This not only made care coordination difficult, but delays during critical moments became frequent, impacting patient outcomes. 

Mile Bluff sought a unified clinical communications platform that could match the urgency and complexity of its clinical workflows. The hospital partnered with Hypercare to integrate on-call scheduling, secure messaging, and code team activations from one central platform.

Clinicians could now instantly identify and contact the on-call team, and over 70,000 secure messages were sent in the first six months. As a result, code activation time dropped from 20-30 minutes to just five seconds. 

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Integrated Scheduling and Messaging

Interoperable communication tools can also improve coordination and continuity of care, as demonstrated by Sault Area Hospital (SAH). 

Prior to using Hypercare, SAH relied on an outdated physician scheduling platform that lacked real-time visibility and syncing. Physicians struggled to see who was on-call, which added barriers to communication and coordination. 

‍SAH chose to partner with Hypercare to improve its semantic and organizational interoperability by implementing the platform for physician scheduling, secure messaging, and a live directory. SAH modernized physician scheduling and improved consult workflows by adopting Hypercare for real-time scheduling and secure messaging. 

Additionally, Hypercare became physicians’ primary communication tool – specifically for consults, as the secure messaging allows for images and lab results to be shared asynchronously. 

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Key Takeaways & Next Steps

To recap, the four levels of interoperability in healthcare are:

1. Foundational interoperability
2. Structural interoperability 
3. Semantic interoperability 
4. Organizational interoperability 

Healthcare organizations must advance through all four levels of interoperability to achieve the safety, efficiency, coordination, and quality improvements that modern healthcare demands. The investment in healthcare IT only pays off when data doesn't just move but is actually understood, integrated, and used to improve patient care.

Evaluate your existing platforms to understand what level of interoperability you’re at and where you need to improve. If your current systems aren’t meeting every level of interoperability, consider exploring a clinical communication platform like Hypercare that supports full interoperability and secure communication. To learn more about Hypercare’s unified clinical communications platform, book a demo.