JMIR Publications

ABSTRACT

The idea of a portable medical record was first federally codified with the Health Insurance Portability and Accountability Act (HIPAA) in 1996. Three decades and several well-intentioned statutes later, the overall medical record remains largely unportable. These efforts have primarily failed because the work requirement to create interoperability has largely been assigned to those who have the least to gain from creating an interconnected network. In this viewpoint we propose a solution to these historical halting efforts, a Federal Health Interchange (FHI). The FHI structure is a minimal national spine composed of a patient index, critical care attributes needed for emergency care, and pointers to records that remain with the providers who hold them. Much of this architecture already appears in the voluntary Interoperability Framework of the Centers for Medicare & Medicaid Services (CMS); our contribution is the mechanism that makes participation a condition of federal payment. Providers register encounters rather than transferring charts. Every federal claim must refer to a registered encounter. The reference resolves or it does not, which makes compliance a matter of record rather than assertion. Three severable legal bases support the design: federal spending power for claims submitted to Medicare and Medicaid, the Commerce Clause through health information technology certification, and patient direction under HIPAA for commercially insured records. The architecture is assembled from certified interfaces that already exist rather than from technology that must be built. Benefits include access to a patient's electronic health records (EHR) at any point of care, emergency access to allergies and medications, patient custody of their complete record across all providers, federal clinical corroboration for fraud enforcement that currently operates on claims data alone, and a research substrate that opens up population-level insights. Limitations concerning coverage, patient matching, and surveillance are addressed directly.