The Behavioral Health Information Technology (BHIT) Initiative is addressing the need for improved data exchange in behavioral healthcare settings. Nine new pilot projects will advance health data exchange to improve behavioral health care coordination. View press release announcing the pilot projects

BHIT Initiative 

The BHIT Initiative is a $20 million effort led by ASTP/ONC and the Substance Abuse and Mental Health Services Administration (SAMHSA). The effort includes partnering with the industry to develop the USCDI+ Behavioral Health (USCDI+ BH) dataset and the FHIR® Behavioral Health Profiles Implementation Guide (BH IG) to provide standardized data elements and technical specifications to improve the state of behavioral health data exchange across care settings. The pilot projects will test the USCDI+ BH dataset and the FHIR® BH IG to assess behavioral health data exchange in real world settings across the country.   

Pilots Selected 

The testing will not only improve the standards and technical specifications of the USCDI+ BH dataset but will also provide vital information about providers’ implementation experience as well as legal and policy considerations for the broader provider community. Pilot participants represent 45 exchange partners across Colorado, Connecticut, Delaware, Florida, Massachusetts, North Carolina, Oregon, Rhode Island, and Washington, DC. Along with technical assistance, ASTP/ONC and SAMHSA will provide funds ranging from $300,000 to $690,000 to implement innovative, community-driven projects that test the USCDI+ BH dataset and FHIR® BH IG, and support improved behavioral health information exchange over the next year. 

The pilot projects will identify effective practices and opportunities that can support improved behavioral health data exchange for patients and providers. This includes care coordination, federal and state reporting, patient access and consent, and consent management for entities covered by federal requirements for the confidentiality of substance use disorder patient records (42 C.F.R. Part 2). 

Many pilot projects also are leveraging health information exchanges as infrastructure for data sharing, and two are exploring innovative uses of artificial intelligence alongside the use of USCDI+ BH data elements. Importantly, these pilot projects include participants at varying levels of health IT maturity, increasing the likelihood that the solutions developed can scale across diverse provider types and settings. 

Looking Ahead 

The pilot projects have already begun the initial phase of their work, and will be complete by the end of 2026. The lessons learned from the pilot projects will inform refinements to the USCDI+ BH data elements and FHIR® BH IG technical specifications. The knowledge gained also will shape the development of the Behavioral Health Information Resource – a comprehensive tool that incorporates lessons learned and best practices from the pilots, with a planned release in 2027. Stay tuned for more updates and find the informational resource on our website next year. 

These pilot projects represent an important step toward a more interoperable healthcare system that supports integrated behavioral and physical health care. By testing standardized data exchange in real-world settings across the country, we’re building the foundation for scaled adoption that can improve continuity of care, improve exchange of data across care settings, and deepen the connection between two parts of the healthcare system that are often siloed.  

Stay Engaged 

We encourage stakeholders to stay tuned for updates on pilot project progress and for opportunities to provide feedback on the USCDI+ BH dataset and FHIR® BH IG.  

This blog post was co-authored with Christopher D. Carroll, the Principal Deputy Assistant Secretary for Mental Health and Substance Use at the Substance Abuse and Mental Health Services Administration (SAMHSA). 

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ASTP/ONC is committed to developing the best methods for the access, exchange, and use of electronic health information (EHI), through the adoption of standards and through the ONC Health IT Certification Program. In this RFI, we invite the public to comment on how standards and certification criteria can support the exchange of diagnostic images for the benefit of patients and providers.

Behind every image is a patient waiting for answers. Ensuring those images move seamlessly between care teams means those answers can come faster, with greater accuracy and at a lower cost. We want to know how we can make diagnostic images more accessible to the providers and patients who need them. Let us know what is working, what is not, and how an optimal, yet unrealized, future state can be architected by regulation, reimbursement, and private sector coordination. Your input will help inform considerations for potential future standards and certification criteria for future rulemaking. Comments will be due 45 days after publication of the RFI in the Federal Register.

Read the Diagnostic Imaging RFI.

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This quote from Warren Buffett on investment portfolios could describe the evolution of patient engagement over the past decade. Much like a carefully built portfolio, the dividends from years of investments in health IT continue to emerge. It is useful to take stock of the dividends of our digitization efforts.

In our first post in the Digital Dividends blog series, we explored how more individuals than ever are accessing and using their health information online, especially those managing chronic conditions or a recent cancer diagnosis. In this post, we look at how U.S. hospitals are helping enable that access, with a focus on where policy priorities, patient demand, and industry efforts have aligned to deliver on the promise of digitalization.

The Eras of Patient Engagement

Our recent data brief shows widespread adoption of patient engagement capabilities among hospitals. Patients can now view, download, and transmit their health data; import records from other organizations into a patient portal; view clinical notes; access information via apps; submit patient-generated data; and securely message providers.

Figure 1. Non-federal acute care hospitals’ adoption of nine patient engagement capabilities, 2024

Source: 2024 American Hospital Association Information Technology Supplement.
Notes: PGD= patient-generated data. For more details, please see the data brief.

After more than a decade of policy making and private-sector innovation, patient engagement has unfolded in three eras coinciding with evolving phases of policy: foundational, emerging, and advanced. These eras are not defined by adoption rates alone but by policies and innovations that set the stage for hospitals to invest in patient engagement capabilities.

The Foundational Era of patient engagement was spurred by the HITECH Act and the Promoting Interoperability Programs (formerly Meaningful Use), which incentivized hospitals to adopt and demonstrate meaningful use of certified electronic health record technology. Foundational patient engagement capabilities – such as viewing medical records and messaging providers –were supported. In 2012, prior to the PI program, only 24% of hospitals provided patients with the capability to electronically view their health information. In 2025, 80% of hospitals reported adoption of all four foundational capabilities (view, download, transmit, and message), with nearly all hospitals (99%) enabling patients to view their health information electronically.

The Emerging Era of patient engagement focused on expanding transparency and choice. This was driven by the 21^st Century Cures Act and reinforced by subsequent Information Blocking regulations, which focus on reducing impediments to the access, exchange, or use of electronic health information. This era spurred hospitals’ adoption of capabilities to enable patients to have electronic access to their clinical notes and access their health information electronically via smartphone health apps. Now, more than 4 in 5 hospitals report supporting patient access to their information via apps, with 70% enabling HL7® Fast Healthcare Interoperability Resources® (FHIR®) based app access.

We are now in our Advanced Era of patient engagement where hospitals are increasingly allowing patients to import and upload their own data, a key advancement in patient-centered care. Currently, less than half of hospitals enable this capability, which had not previously been driven by federal policy or incentives. Nevertheless, we note that there has been an upward trend in growth showing hospitals’ readiness to support more connected patient access and engagement. The Trump Administration earlier this summer announced progress toward building a smarter, more secure, and more personalized healthcare experience in partnership with innovative private sector companies. Through its most recent Health Tech Ecosystem announcements, CMS also issued a call to action urging exchange networks, payers, providers, and developers to move toward the “advanced era” of patient engagement.

Figure 2. Non-Federal Acute Care Hospitals’ Adoption of Foundational, Emerging, and Advanced Engagement Capabilities in Any Setting: 2021-2024

Source: 2021-2024 American Hospital Association Information Technology Supplement.

Notes: “Foundational” refers to hospitals with early core patient engagement capabilities (view, download, transmit, secure messaging); “Emerging” includes those that added newer Cures Act–related capabilities (clinical notes and patient app access); and “Advanced” covers capabilities not yet required or incentivized (data import and patient-generated data [PGD]). *Indicates statistically significant difference from the same group in the preceding year at the 5% level. For more details, see the data brief.

The New Digital Health Norm

Since the onset of the COVID-19 pandemic, patients have come to expect a “new normal” regarding engagement with their health information. Demand for electronic access has surged, with patients now expecting near-instant access through smartphone apps. Our recent brief shows that federal policies and incentives aimed at enhancing patient access and hospitals’ achievements in offering these capabilities to patients have contributed to greater access and innovation.

Variable Returns and Looking Ahead

Community hospitals are the primary source of care for many Americans, and hospitals have been crucial enablers of electronic health information access. However, these gains have not been uniform. The foundational capabilities are nearly universal across hospitals, but more advanced capabilities like importing records and patient-generated data still lag among lower-resourced hospitals. These variable returns reflect the differences in hospital resources and vendor capabilities and have downstream implications for the patient populations they serve.

Looking ahead, the federal government, working alongside the health IT community, provider groups, payers, patients, and other stakeholders, will continue the hard work of advancing patient empowerment. Policy support and technical progress will be essential to ensuring that all patients have access to the most impactful patient engagement capabilities. The health technology ecosystem recent request for information from CMS and ASTP/ONC underscores the need to expand access to technologies that empower patients to make informed decisions. Public responses offer us insights into where we have made progress and where more work is needed. Above all, patients want reliable, secure, and user-friendly systems that work for them. As we reflect on these responses, they’ll help us shape our policy priorities surrounding patient access to their health information.

As this blog series continues, we will examine additional dividends and where our investments in digital health continue to yield value.

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HHS is especially interested in comments from those building AI tools for clinical settings, those buying or implementing AI tools for clinical settings, and those who want to use AI in clinical care but face barriers. Your input will inform how HHS uses three major levers: regulation, reimbursement, and research and development. 

Comments will be due 60 days after publication in the Federal Register, so now’s the time to put your thinking caps on. 

Read the AI RFI

Today we have also released a handful of new information blocking FAQs, including one that addresses practices that interfere with automation technology’s ability to access, exchange, or use electronic health information. The other new information blocking FAQs can be found on our main FAQs page and are directly accessible through these links: 

• Related to revenue sharing 

• Related to the requester’s role in the Manner Exception 

• Related to electronic health information’s scope and the Manner Exception

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How TEFCA and CMS-Aligned Networks Relate

To start, both TEFCA and CMS-Aligned Networks are built around the same objective – supporting patients, providers, and other authorized entities in securely accessing and exchanging the electronic health information needed to improve care and reduce burden. Building on this shared purpose, CMS created the CMS-Aligned Network pledge criteria to give any network – including new entrants and networks with different business models – a pathway to accelerate interoperability capabilities. Participation is open and voluntary, and it complements TEFCA rather than replacing it. In fact, all the organizations who have become Qualified Health Information Networks (QHINs) under TEFCA have also pledged to be a CMS-Aligned Network. That’s why the combination of these two initiatives is so powerful.   

TEFCA implements the 21^st Century Cures Act’s requirement to establish a Common Agreement for participating parties involved in network-to-network exchange, whereas CMS has given networks the opportunity to publicly step up and “do more, faster.”  Any organization that self-identifies as a network and agrees to meet the CMS Interoperability Framework can pledge to be a “CMS-Aligned Network.” While the CMS-Aligned Network pledge does not establish a centralized network governance structure like TEFCA, CMS actively defines the expectations for pledgees and convenes technical working groups to shape the criteria and measures of success.

Through this collaborative process, pledgees commit to shared goals, contribute to the development of common approaches, and are expected to make steady progress. CMS may remove organizations that no longer meet the criteria, and pledgees may withdraw voluntarily if they are no longer aligned. CMS-Aligned Networks must meet HITRUST requirements and fully comply with HIPAA rules and all other applicable privacy and security laws and regulations. 

TEFCA provides one set of network participation policies, one set of nationwide connectivity services, and one approach to network oversight for all participants. Having gone live at the end of 2023, TEFCA’s governance has matured into a participatory, public-private, collaborative model. Additionally, for a health information network to become a QHIN under TEFCA and demonstrate it is up to the task of facilitating cross-network exchange, at nationwide scale, the requirements are rigorous and specific. Not only do such networks need to address aspects like cybersecurity insurance, annual third-party security assessments, and U.S. ownership status, they also need to demonstrate their technical competencies as part of a regimented onboarding process. Moreover, QHINs are also required to ensure Participants and Subparticipants within their network adhere to specific terms of participation, which is a level of operational network policy that is not necessary for the CMS-Aligned Network pledge program. 

Different Paths to Accelerating Interoperability

Where TEFCA looks to be a rising tide that lifts all boats, networks that have pledged to be a CMS-Aligned Network are more like speedboats shooting out ahead to achieve specific milestones. For instance, one CMS Interoperability Framework criterion applicable to CMS-Aligned Networks is that networks provide “an accounting record of all network-facilitated transactions, including for treatment, (who accessed patient’s data, when, and why) and ensures a timely response for each request.” Similarly, the CMS Interoperability Framework expects that “patient consent preferences, when included in a transaction, must be shared with all involved parties, including for treatment use cases.” Implementing these pledge criteria is as important as it will be challenging because they go considerably beyond current policy baselines and require a level of automation and process standardization not yet universally in place in health care.

Similarly, the CMS Interoperability Framework spotlights “patient appointment and encounter details” for accelerated effort by each individual CMS-Aligned Network, whereas this use case does not necessarily fit TEFCA’s focus on cross-network exchange. TEFCA and the CMS Interoperability Framework share the most commonalities in terms of underlying technical expectations. Both reference support for USCDI, HL7® FHIR®, and IAL2 and AAL2 from a digital identity perspective as well as expected capabilities and timeliness for record location and query.  

The main difference is the pace and structure. TEFCA progresses through a formal, stepwise governance process, while CMS-Aligned Networks evolve through an ongoing connect-a-thon style model that encourages rapid testing, learning, and refinement. The two approaches are complementary – one provides stability, the other accelerates innovation. 

Ultimately, TEFCA will be better off to the extent that CMS-Aligned Networks are able to achieve their pledges and, collectively, we are able to advance efforts to empower patients with their electronic health information and leverage interoperability to reduce administrative burden. We look forward to continuing to advance TEFCA and remain committed to its growth. 

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The SOP details how government entities at the federal, state, local, or tribal level can leverage TEFCA to obtain information needed to determine an individual’s eligibility for non-health care government benefits. The Government Benefits Determination Exchange Purpose includes a sub-exchange purpose that supports two SSA programs that provide benefits based on disability: the Social Security Disability Insurance program (title II of the Social Security Act) and the Supplemental Security Income (SSI) program (title XVI of the Act). By obtaining medical records through interoperability networks supported by TEFCA, SSA can accelerate disability determinations through faster medical record collection – which could take minutes or seconds instead of weeks or months for traditional methods. This in turn can reduce SSA’s operating costs by eliminating the need to print and mail documentation.

Technological requirements have also been updated to make this a reality. The Qualified Health Information Network® (QHIN^©) Technical Framework Agreement (QTF) Version 2.1 was updated to help make this process more efficient and facilitate implementation of the SOP. The update ensures that requests from government entities for benefits determinations are efficiently routed to specific organizations that the government knows are stewarding the information needed, rather than openly querying the entire network.

The 11 QHINs will implement updates to align with these documents and the updated Exchange Purposes SOP. ASTP/ONC is thrilled to work with our federal and non-federal partners to make sure TEFCA continues to support the needs of the care community. To keep abreast of all the recent TEFCA updates, we recommend following along through the new transparent process for amendments to framework agreements, technical requirements, and SOPs by visiting the RCE’s Topics in Change Management page.

View the SOP

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Let’s look at the policy triangle that affects each network participant’s sharing posture. On the first side, there’s the HIPAA Privacy Rule that permits but does not require responses to network queries for treatment purposes. On the second side of the policy triangle, there’s the information blocking regulations, which change the “you can share” electronic health information posture to a general expectation that “you will share.” The Trusted Exchange Framework and Common Agreement (TEFCA) is the third side of the triangle. TEFCA’s Common Agreement for QHINs and Terms of Participation for all other Participants and Subparticipants serve as obligations among all those within TEFCA and specify when they must share with each other.  

So… if there’s a regulation that says when you’re permitted to share health information, another that says when you ought to share, and agreements in place that say when you must share, what’s the holdup? To answer with two phrases: “stranger danger” and “interpretative drift.” 

Trust Among Strangers – at Scale

TEFCA’s cornerstone is its ability to scale connectivity nationwide by, among other things, establishing the trust conditions necessary to automate responses to network queries between parties that have never exchanged with each other. To establish this kind of trust, we need aligned interpretations of key definitions and appropriately rigorous network entry processes. This means those who join TEFCA will need to put in more work upfront. TEFCA’s directory infrastructure also has protections in place to prevent its Participants and Subparticipants from querying for exchange purposes for which they are not authorized. Moreover, TEFCA’s governance includes processes for identifying potential misuse of authorized exchange. Despite these risk mitigations (that can evolve as the network matures), TEFCA’s scale has, almost inevitably, led some participating in TEFCA Exchange to give more thought to the “strangers” to whom they’re responding.  

I’ll… take… is it Treatment for $800, Alex

Every HIPAA-covered health care provider that participates in TEFCA should be able to query any other HIPAA-covered health care provider also participating in TEFCA for treatment purposes and expect a response. Simple, right? Not so fast. At present, representatives from QHINs, Participants, and Subparticipants are deliberating 25 years of interpretative differences on what constitutes “treatment” and who’s considered a “health care provider” under HIPAA. Subtle differences in interpretation on the ground can have substantive impacts on perceived risk and network participation, which can grind information sharing to a halt. When a requester describes its rationale for making a treatment query and a responder (who is a HIPAA covered entity or business associate and accountable under HIPAA for its disclosures) disagrees that the request is for “treatment,” we reach an information exchange impasse.  

Unifying these interpretative differences is a key part of the hard work that our private sector colleagues have committed to doing through TEFCA. Continued efforts to drive to interpretative consensus, combined with disciplined onboarding processes and fair auditing and adjudication of disputes, can go a long way to bring TEFCA’s promise to fruition.  

Every day, as we tackle these detailed (and at times tedious) discussions, we’re appreciative of the engagement and investment that our colleagues have made to bring TEFCA Exchange to the nation. More than 60,000 locations are now connected through TEFCA and we’ll keep working to make sure everyone can continue to benefit from its one set of network participation policies, one set of nationwide connectivity services, and one approach to network oversight. 

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It doesn’t have to be this way. The Trusted Exchange Framework and Common Agreement (TEFCA) includes Government Benefits Determination as one of the six authorized Exchange Purposes and seeks to automate this records request process. Doing so will make it possible for SSA and other similar agencies to more quickly get the information they need and less burdensome for health care providers to respond. In fact, the SSA estimates that on average it identifies allowances nearly 60 percent faster when processing applications with only health IT records. By leveraging the scale and connectivity TEFCA offers, it will be possible for individuals to get more timely responses from government agencies. Put simply, for patients this means quicker disability coverage, and for providers this means less uncompensated care.

The TEFCA Recognized Coordinating Entity^® (RCE^®) is planning to release an important update to TEFCA’s underlying technical specifications. The Qualified Health Information Network® (QHIN) Technical Framework is being updated to more clearly support directed queries, which allow for more precise requests for medical records to be issued across QHINs. These updates will be implemented by the 10 designated QHINs and will help ensure that government benefits determination requests are efficiently routed, thus eliminating unnecessary queries across the network. These changes will also support those participating in TEFCA that are implementing Health Level Seven® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) APIs. Additional implementation specifications will be established in the forthcoming Government Benefits Determination Standard Operating Procedure.

We are just getting started! TEFCA is expanding to support the needs of the broader care community, and we are thrilled to work with our federal partners to make that possible.

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Hospital and Clinician use of Certified Health IT

ASTP/ONC and Centers for Medicare & Medicaid Services (CMS) coordinated the release of new 2023 data on the certified health IT used by hospitals and clinicians for participation in the Medicare Promoting Interoperability (PI) Program and the Promoting Interoperability performance category of the Merit-based Incentive Payment System, respectively. Eligible hospitals and eligible clinicians use certified electronic health record technology to meet annual program requirements.

For hospitals, only 2023 data are currently available, but we look forward to coordinating on future releases soon. For clinicians, 2023 data is now available, along with data from 2019-2022. The datasets merge Medicare PI Program and Merit-based Incentive Payment System data with the ONC Certified Health IT Product List (CHPL) to link hospital and clinician participants with the specific certified technologies reported for each performance year. Each dataset includes hospital and clinician identifiers, so they can be further linked to other health care datasets that can enrich and broaden their use.

Hospitals’ Participation in Health Information Networks

Through ASTP/ONC’s partnership with the American Hospital Association (AHA), we support the annual fielding of the Information Technology Supplement to the AHA Annual Survey of US hospitals. The supplement has long asked hospitals about their participation in health information networks, including regional, state, and local health information exchange organizations (HIEs); national networks; EHR vendor networks; and, now, active and planned participation in a Qualified Health Information Network®, as part of the Trusted Exchange Framework and Common Agreement.

We’re pleased to make a new dataset available that pools hospital responses to these relevant questions from 2022-2024, representing each hospital’s most recent report of participation in these various networks. In all, over 3,000 non-federal acute care hospitals are included across these 3 years of survey data. The dataset includes hospital identifiers to enable data linkages; however, given that this is pooled survey data and does not represent a census of hospitals, data users should be considerate of non-response bias when generalizing the data.

We hope this dataset encourages interest in the larger IT Supplement data, which is available through the AHA, and includes a larger set of topics, including hospitals’ use of artificial intelligence, health information exchange partners, information blocking, and more. The data could also be linked to the above PI Program dataset to generate insights across both sets of data.

New and Historic Data on Health App Marketplaces

Beginning in 2019, ASTP/ONC began studies of various public-facing app marketplaces (or galleries) hosted by both EHR companies and innovative organizations. We published initial results of our study measuring and presenting an initial baseline understanding of how many companies were actively pursuing integrations with EHRs and creating innovative applications to enrich the ecosystem of applications and services available to EHR users.

We now provide a new dataset of the list of apps and software applications discovered via these sources for years 2019-2025 for public use. The dataset represents a “snapshot” of all the apps featured at these data sources for each of the years, and contains information pulled directly from each website, including application name, developer name, and application description. We’ve long used this project to study the emergence of new technology (even the first ambient scribe) and in what ways health care innovators, start-ups, and digital health companies are delivering new technologies that can help solve and improve health tech’s (and health care’s) biggest challenges. We believe the time is right—and the data robust enough—to make the dataset available to the entire community for its use and exploration. This data continues to inform ASTP/ONC’s work, including additional studies on digital health company experiences with APIs.

New Data, New Possibilities

We hope this data encourages innovative use, thoughtful questions, and bottom-up approaches to understand these areas of the health IT market. Be on the lookout for future data updates! This is just the beginning of more insights and data for public use coming your way in 2025 and beyond.

Visit healthit.gov/data for more data downloads, quick stats, and brief analyses. There’s something for everyone!

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Laboratory information is critical to medical care, public health, and clinical research, and virtually every person who has received medical care has experienced some type of laboratory testing. The timely and precise reporting of laboratory testing results reduces the risk of diagnostic error and enhances the overall quality of care. Laboratory testing results are often the primary signal shared with public health agencies to alert them to potential public health events, and laboratory data are a critical component of real-world data used to improve healthcare practices. Despite progress in recent years, clinical laboratories still face obstacles with widespread adoption and consistent implementation of data standards. These standards create a shared understanding of data across systems, which is foundational for access to laboratory data.

Improving laboratory data interoperability is a complex task, requiring a multi-faceted approach and years of incremental improvements. The ASTP/ONC report highlights several challenges across the laboratory ecosystem, such as a lack of incentives to do resource-heavy upgrades, habitual use of local or custom codes, delays in updating of terminology and exchange standards, and insufficient training and support. ASTP/ONC explores actionable solutions to address these issues, including incentivizing and requiring laboratories to conform to common standards, conditioning the receipt of federal funding on the use of certified health IT, modernizing public health laboratory technologies, and promoting participation in the Trusted Exchange Framework and Common Agreement (TEFCA). With these actions, laboratory interoperability can become less burdensome and more efficient, and can help patients, clinicians, and researchers receive timely access to information that can improve the quality of care.

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