HIEs are often the foundation of a state’s interoperability. Here’s how to build beyond them for a fuller, more usable picture of rural health at the community level.
What RHTP Asks of States
CMS’s Rural Health Transformation Program (RHTP) is investing $50 billion over five years to improve rural health outcomes. In return, states are asked to show, with data, that rural residents are better off: fewer avoidable ER visits, safer care transitions, and a workforce that stays.
That reporting requirement puts interoperability at the center of every state plan. To measure outcomes at the community level, states need data from the places rural patients actually receive care. That includes hospitals and clinics, but also EMS, mobile integrated health, behavioral health, skilled nursing, pharmacies, tribal health systems and more.
The good news: states have more options for reaching that data than ever before. This guide maps those options, explains how they fit together, and offers five questions to ask as you fund integrations.
Why the Full Landscape Matters
RHTP also asks states to plan for sustainability beyond year five. That makes it worth understanding every pathway available, not just the ones already in place. Each organization on the list above connects differently, and the most efficient route for one may not be the right route for another.
CMS has been working on similar questions nationally through its Health Tech Ecosystem and Interoperability Framework, including the “Kill the Clipboard” effort to make patient information follow the patient. RHTP gives states a chance to apply those same ideas locally, with dedicated funding and a clear timeline.
Start with the Foundation: Your State HIE
For most states, the health information exchange (HIE) is the natural starting point, and for good reason. HIEs have spent years building trusted relationships, governance and technical connections that no RHTP plan should try to recreate.
What HIEs typically bring to the table:
- Hospital and clinic connections already in place, often including admission, discharge and transfer (ADT) alerts
- Established governance and trust frameworks that participants have agreed to
- Public health reporting relationships with the state
- Local knowledge of the providers, systems and relationships in the state
Many HIEs are also expanding their reach, connecting to national networks and exploring new participant types. RHTP funding can accelerate that work.
Where the Community-Level Gaps Are
Some of the organizations RHTP cares most about have historically sat outside traditional health data exchange. That’s usually not because anyone excluded them. It’s because of structural factors that predate RHTP:
- Legal definitions. In a number of states, EMS and mobile integrated health (MIH) teams aren’t recognized as “treating providers.” Treatment is one of the main purposes of use that exchange networks are built around, so these teams often need a different pathway.
- Funding history. Small community organizations, like a rural MIH program seeing 100 to 150 patients a year, have rarely had the budget or IT staff for a traditional integration.
- Consent rules. Behavioral health and substance use records carry additional protections that require specific consent handling.
- Multi-state operations. Vendors serving several states may need a national connection rather than one per state.
These gaps are exactly what RHTP funding is positioned to close. The question is which pathway fits each organization best.
The Interoperability Landscape: Pathways States Should Know
Ask five people how to solve rural interoperability and you’ll hear five answers. Most are partly right, because each pathway serves a different need. A complete strategy usually combines several.
| Pathway | What it is | Best for | Worth knowing |
|---|---|---|---|
| State or regional HIE | Statewide exchange with established local governance | Hospitals, clinics, ADT alerts, public health reporting | The foundation most state plans build on |
| QHINs / TEFCA | National networks exchanging under a common federal framework | Vendors and providers operating across state lines | Many HIEs and vendors already connect here; ask which QHIN each party uses |
| EHR vendor networks | Exchange built into EHRs (e.g., Carequality, CommonWell, Epic) | Providers on major EHR platforms | Often already turned on; may reduce the need for new builds |
| Individual Access Services (IAS) | A TEFCA purpose of use that lets patients retrieve their own records | Reaching patients whose care team isn’t a “treating provider” | Coordinated through The Sequoia Project; match rates are improving quickly |
| Cures Act patient access APIs | Required APIs in every certified EHR, backed by information blocking rules | Patient-directed sharing with caregivers and community teams | Works regardless of which network a system belongs to |
| Other state data sources | PDMP, immunization registry, NEMSIS (EMS data), Medicaid claims | Outcome measurement and population views | Often already held by the state |
Patient-directed pathways deserve special attention for community teams. When a paramedic or care coordinator doesn’t qualify under treatment, the patient in front of them can authorize access directly. National patient access networks have reportedly gone from finding records for about 8% of patients in early 2025 to roughly 70% today, according to network operators. That isn’t complete coverage, but it’s a meaningful complement to what the HIE already provides.
The Real Test: The Person Standing in Front of the Patient
A useful way to evaluate any integration is to picture the person on the ground. Community paramedics often describe home visits where they log into three separate systems to piece together one patient’s history.
The goal of RHTP interoperability isn’t more connections on paper. It’s collapsing those three logins into one for the person delivering care.
Care transitions are where this matters most. A patient with a documented cardiac history arrives at a rural ER late at night. The history exists, but whether it reaches the physician depends on where it lives and which sharing rules apply. When one pathway doesn’t reach, another can: the patient standing right there can often authorize access through a patient-directed pathway.
Give Vendors Room to Choose Their Pathway
Connecting through the state HIE is a strong default, and for many vendors it will be the right choice. For others, a different route may be more efficient:
- An existing QHIN connection, especially for vendors operating in several states
- Identity-verified patient access through a CMS-aligned network
- Patient-directed access under the Cures Act, often the only option for teams outside the treatment purpose of use
Evaluating the outcome rather than prescribing the pathway lets each vendor connect the way that fits its work. Keeping those connection costs manageable also helps the whole network last beyond year five.
Five Questions to Ask As You Fund Integrations
These are worth bringing into your next vendor conversation.
- Which QHIN or network are you on, and how does that relate to our state HIE? If the vendor and the HIE already exchange through the same network, a new direct integration may not be needed.
- Who uses this data at the point of care? Ask for a specific role, like a nurse, paramedic or care coordinator. Data that’s stored is useful; data that’s used changes outcomes.
- Does the data appear inside a tool providers already use, or add a new login? Every extra login is friction for a rural care team.
- Can a patient or authorized caregiver direct their data to flow? Patient-directed access can fill gaps while institutional agreements are still being worked out.
- What does this cost to sustain after year five? Understanding the ongoing cost up front helps states plan for sustainability from day one.
Most organizations will have strong answers to some of these and gaps on others. That’s normal, and those gaps are where RHTP funding can do the most good.
The Measure That Matters
Success under RHTP won’t be measured by how much data moves or how many organizations connect. It will be measured by whether rural residents have fewer avoidable ER visits, safer care transitions, better chronic disease management, and outcomes that reflect what patients themselves said mattered.
Getting there takes every part of the ecosystem: HIEs, national networks, EHR vendors, community teams and patients themselves. When states understand all the pathways available, they can build on what already works and extend it to the people delivering care in the community.
In This Series
We’ll go deeper on each of these topics in upcoming posts:
- RHTP Interoperability 101: a plain-language glossary of QHIN, TEFCA, HIE, NEMSIS and more
- The Community Paramedic Test: what a useful connection looks like on a home visit
- Choosing a Pathway: QHIN, HIE or patient-directed access, and when each fits
- Care at 3 A.M.: following one patient through a rural care transition
- Patient Record Access: how the Cures Act supports vendor choice
- Stored vs. Used: evaluating whether an integration will outlast the grant
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