Our healthcare interoperability highway is incomplete, with traffic often flowing only in one direction in segments of the healthcare data interstate system. The bidirectional foundation, comprising large, legacy providers and health systems utilizing enterprise EHRs, is, for the most part, strong. However, large swaths of the ecosystem, such as innovative new market entrants and participants that lack the scale (or the wallet) to adopt traditional EHRs, are often optimized to receive, not transmit data.
Today’s treatment-based exchange networks depend on shared participation. The expectation is simple: if you can retrieve data, you should also contribute data. In practice, that balance does not always hold. Some participants take far more than they give and quality varies across all segments. Over time, that creates an uneven system. Data holders begin to question the value of participation. Records become fragmented. Trust erodes.
This is not a theoretical concern. It shows up in governance discussions across national frameworks, where questions about fairness and reciprocity are becoming more common. Interoperability cannot function solely as a system of extraction. It must operate as a system of contribution. Reciprocity ensures two-way flow.
What reciprocity means in practice
Reciprocity, often referred to as shareback, is the idea that data exchange should produce a continuous cycle of improvement. It starts when a provider retrieves information from the interoperability networks that fills in the gaps in their local patient record. That information provides critical, sometimes life-saving, context for ongoing care. The outcome of that care, new findings, updated diagnoses, treatment decisions, is then shared back in a structured and usable way.
Without that final step, the value of the original exchange is limited. Each interaction becomes isolated rather than cumulative.
When reciprocity is present, the system improves with use. Records become more complete. Care teams have better context. Future decisions are made with stronger information. When it is absent, the system stalls.
Why the current model falls short
Most interoperability infrastructure was designed to support access. Query and retrieval workflows are well understood and widely implemented. Contribution workflows are not.
There are several reasons for this. Clinical outputs do not always fit cleanly into existing standards. Workflows are not designed with shareback in mind. Governance frameworks assume reciprocity but often do not define or enforce it in a consistent way.
The result is a system that works well for pulling data but not for pushing meaningful updates back into the network. This is where the next phase of interoperability must focus.
Why this matters for care and innovation
The absence of reciprocity has real consequences. Incomplete records can lead to missed context, redundant testing, and delays in care. At a system level, it becomes difficult to measure whether interoperability is improving outcomes. We can count connections and transactions, but not impact.
Reciprocity changes that. When care outcomes are shared back into the network, interoperability becomes measurable. It becomes possible to see where data exchange influenced decisions and where it improved results.
This also affects innovation. Advanced analytics and AI depend on complete and current data. When key information is not returned to the ecosystem, the value of these tools is constrained.
A system that learns requires a system that shares.
Moving from principle to expectation
Reciprocity is not a new idea – at least for our interoperability networks. It is already embedded in the assumptions behind nationwide frameworks such as TEFCA and Carequality. Participants are expected to both access and respond to data. Additionally, reciprocity is enabled “out of the box” by all certified EHRs. However, even when sharing is technically enabled by an EHR, individual provider configuration choices and disparate clinical workflows can create tremendous variance in the quality and quality of what is shared.
The reciprocity challenge is compounded once you move into the parts of the clinical community that either cannot afford certified EHRs or prefer to use home-grown, often AI enabled systems that were not designed with transitional interoperability in mind.
Regardless of the network or technology, reciprocity needs to be designed into workflows and enabling technology from the start. It should be part of onboarding, part of governance, and part of how performance is evaluated. It should be clear what types of information are expected to be shared back, when, and in what form. Most importantly, it needs to be treated as a core requirement with clear standards that make allowances for the scale, nature, and maturity of the clinical practice.
The next phase of interoperability
Healthcare has made real progress in connecting systems and enabling access to data. That foundation matters. But access alone is not enough. The next phase of interoperability will be defined by whether the system can learn from itself. That requires closing the loop between retrieving data and contributing back to it.
Interoperability is not a one-way pipeline. It is a two-way street.
If the industry embraces that principle in practice, not just in theory, interoperability can move beyond data exchange and begin to deliver measurable improvements in care.
Patrick Lane
Patrick Lane is President of Health Gorilla.
