The Interoperability Problem Is About Policy, Not Technology

A look at real-world examples from the United States, United Kingdom, Nigeria, Kenya, and Estonia

Recently, I’ve been asking myself why medical records don’t move with patients as easily as they should.

As a registered nurse who worked in Nigerian hospitals and now studies digital health policies, I’ve seen what happens when a patient’s medical history isn’t available. Unnecessary repeat tests, medication mistakes, and preventable problems are common. With all our technology in 2026, why does this keep happening?

Out of curiosity, I started looking into this issue in late 2025. What surprised me wasn’t a lack of technology; it exists. The real problem was something else. In this article, I’ll share what I learned from case studies in the United States, the United Kingdom, Nigeria, Kenya, and Estonia.

My goal is to show you, whether you work in healthcare, policy, tech, or are just frustrated by how your own medical records are handled, that interoperability isn’t failing because of technology. It’s failing because policy allows it.

Let’s begin.

First, what does interoperability mean?

If you’ve ever filled out the same medical history forms at a new doctor or hospital, you’ve experienced the interoperability problem.

Interoperability means different healthcare IT systems can share and use patient data in a useful way. When it works, your records from one hospital are available right away at another. Your primary physician can see what the specialist has prescribed before. The emergency room knows your medication allergies, even if you can’t speak.

The main technology standard for this is HL7 FHIR (Fast Healthcare Interoperability Resources), which has been used worldwide since 2014. It works like a universal language for health IT systems, much like how an iPhone can text an Android phone.

In short, the technology is mature and proven. So why isn’t everyone using it?

That’s what I wanted to find out.

The Story That Inspired This Article

Let me begin with three patients in three different countries, with similar scenarios:

In California, United States, we see a 68-year-old woman arrive at a hospital emergency department with crushing chest pain at 2:47 AM. She’d been to a university medical center just two weeks earlier for a complete cardiac workup, such as a stress test, echocardiogram, CT angiogram, the works, etc. Those results could save her life right now, but they can’t access them, and this is not because the technology doesn’t exist. Both hospitals use electronic health record systems that support FHIR. They simply don’t connect them. So the ER doctor starts over. Orders another CT angiogram, unnecessary radiation exposure, 40 precious minutes lost while her heart muscle is actively dying.

In London, United Kingdom, we see a 72-year-old man is admitted to an NHS hospital trust for pneumonia. His GP prescribed him warfarin (a blood thinner) three months ago after a stroke. But the hospital’s system can’t see the GP’s records. No one knows he’s on warfarin. They give him aspirin. He develops a brain bleed. This scenario occurs more than 31,000 times a year in the NHS, where we see medication errors during hospital admission because systems don’t communicate with one another.

In Lagos, Nigeria, A 28-year-old pregnant woman goes into labor. She has been receiving antenatal care at a private clinic for nine months, the full antenatal package. But she delivers at a public hospital because it’s closer to her home. The obstetrician has none of her records. No blood type. No history of gestational diabetes. No record of her previous cesarean section. They’re starting from zero, and both mother and baby are at risk as a result.

Three different continents with the same problem. What shocked me when I started doing some research was that this was not happening because the technology to share these records didn’t exist, but was happening because policy allows health systems to choose not to share them.

Case Study 1: Estonia Is Proof That It Can Work

Before I talk about the failures, let me show you what success has been achieved.

Estonia, a small Baltic country with a population of about 1.3 million, has achieved something incredible, which is, 99% of its health records are digitized with full nationwide interoperability. And they’ve been doing it successfully for over 20 years.

Here’s how it works: Each citizen has a digital health record that any healthcare provider in the country can access through a system called X-Road. When you visit any clinic or hospital in Estonia, the doctor can immediately see your full medical history.

But here’s the interesting part: they use the same technology that everyone else can access, which includes HL7 FHIR and standard APIs. There’s nothing unique about the technology in Estonia.

So what’s different? The digital health policies.

Estonia’s policy approach:

• Government mandate: All healthcare providers must connect to the national health information system. If you want to practice medicine in Estonia, your system has to be interoperable.
• Patient control: Estonian citizens own their health data. They can see exactly who accessed their records and when, thereby promoting complete transparency through audit trails.
• Open standards: The X-Road infrastructure is open source (you can find it on GitHub). The government doesn’t allow vendor lock-in.

As of 2026, Estonia saves more than 1,345 years of working time every year thanks to its digital health system. That’s time doctors and nurses don’t spend searching for patient information, making calls, or sending faxes. Instead, they spend it on patient care.

When I learned this, my first thought was: if Estonia solved this 20 years ago with the same technology we all have, why hasn’t everyone else done it?

Let’s see why.

Case Study 2: United States Shows That The Law Isn’t Enforced

The United States has a straightforward story, in my opinion.

In 2016, the U.S. Congress passed the 21st Century Cures Act, which explicitly banned “information blocking”, the practice of preventing the access, exchange, or use of electronic health information. The law was clear. The penalties were severe, with penalties up to $1 million per violation. It took effect in April 2021.

But for more than two years, nothing happened. I’d call this poor implementation.

From 2016 to 2023, no penalty was given.

I had to read this several times to believe it. The U.S. has a law banning the exact problem we’re discussing, with million-dollar penalties, but for years, no one enforced it. Enforcement for vendors didn’t start until September 2023. For healthcare providers, it only began in July 2024. Even in early 2026, there’s still no public record of any major penalties.

What happened in late 2024 that’s important to note: In December 2024, ONC finalized the HTI-2 rule with new interoperability requirements. However, with the change in administration in January 2025 and a broader deregulatory push, there remains significant uncertainty about whether these standards will be meaningfully enforced.

Epic Systems, the largest EHR vendor in the U.S., controls 42.3% of the hospital market and 54.9% of hospital beds (according to KLAS Research’s May 2025 report). Oracle Health (formerly Cerner) controls another 22.9% of hospitals. Together, these two companies dominate 65% of the acute care market.

Here’s the business model from my observation, switching EHR vendors costs large health systems over $100 million and takes three to five years. Once a hospital chooses Epic or Oracle, they’re locked in for 10 to 20 years. If patient data moved freely between systems, switching would be easier. Vendors and hospitals know this.

Epic also has a feature called “Care Everywhere” that enables data sharing using FHIR. So the technology exists, but it’s not turned on by default. Health systems most of the time have to pay extra to enable it, and even when it’s activated, it has functional limitations.

This is what I call compliance theater: meeting the requirements on paper, but making sure it doesn’t work smoothly in practice.

What about the human cost? According to CRICO Strategies (a medical liability insurance provider), duplicate patient records cause nearly 2,000 preventable deaths every year in the United States. The healthcare system wastes an estimated $200 billion annually on unnecessary testing and treatment, much of it because doctors can’t access test results from other facilities.

But here’s what gives me hope: the VA-DoD exchange shows it can work in America.

As of 2026, the Veterans Affairs and Department of Defense continue to successfully exchange patient records for 9 million veterans across 1,243 VA healthcare facilities using FHIR-based infrastructure. When a service member transitions from active duty to veteran status, their complete medical history follows them seamlessly.

What’s the difference? Federal mandate. When the government requires it, funds it, and holds people accountable for it, interoperability works, even in the fragmented American healthcare system.

The lesson is clear: technology isn’t the barrier. Enforcement is.

Case Study 3: The United Kingdom Shows Why Voluntary Standards Don’t Work

The NHS should have every advantage, as it’s a unified national health system with centralized governance and ample resources. If any country should have solved interoperability by now, it’s the UK.

Yet as of 2024, 33% of NHS hospital trusts still cannot electronically access patient data from outside their organization. (This is from NHS Confederation reports published in late 2024.)

Despite 91% of trusts having electronic patient record systems, they don’t connect to each other. The result: 9.1% of all patient interactions, over 11 million occasions annually, involve clinicians trying to navigate incompatible systems. According to a JMIR Human Factors study published in August 2025, this fragmentation causes 1.8 million medication errors every year during care transitions, with 31,604 resulting in actual patient harm.

Think about that. Nearly 32,000 people are harmed every year in one of the world’s most advanced healthcare systems, not because of medical knowledge gaps or lack of treatments, but because one part of the NHS can’t see what another part prescribed.

So what exactly went wrong?

Until August 2025, interoperability standards in the NHS were voluntary. Individual hospital trusts chose their own systems based on local procurement decisions, vendor relationships, and budget constraints. The NHS spent 70–85% of its technology budgets just maintaining these fragmented legacy systems instead of connecting them.

But the good news is thar the UK is finally fixing it.

In August 2025, the Data (Use and Access) Act made NHS information standards mandatory for all IT suppliers. For the first time, the Health Secretary has the authority to impose fines for non-compliance. The NHS has announced plans for a Single Patient Record accessible via the NHS App by 2028, though as of early 2026, implementation is still in its early phases with incremental progress being made across trusts.

This is exactly the policy intervention needed. The NHS estimates it could save £340.5 million over the next ten years just from improved interoperability compliance.

But it came decades late. If these requirements had existed when the NHS first started digitizing, Britain wouldn’t be facing this crisis now.

The lesson: voluntary standards are ignored. Mandatory standards get implemented.

Case Study 4: There are no solid enforcements in my home country, Nigeria.

Nigeria’s challenge is the most fundamental of all: there is no national authority with the power to enforce health informatics standards.

Let’s think about what this means in practice. Nigeria has a federal structure with 36 states plus the Federal Capital Territory. That’s 37 independent health systems with no mandate to connect with one another. The National Health Insurance Scheme (NHIS) exists in silos across multiple directorates. Private healthcare providers, who deliver roughly 70% of healthcare in Nigeria, operate almost entirely disconnected from public systems.

And what really frustrates me, while I was working in Nigerian hospitals, is that I constantly saw this problem every single day. A patient comes in from another hospital, and we have to start their entire medical history from scratch. Sometimes they remember their medications. Sometimes they don’t. Sometimes they bring paper records. Sometimes those papers are illegible or incomplete.

A 2025 digital health maturity assessment of ten Nigerian states (published in medRxiv) found the same problems everywhere: fragmentation of platforms, absence of governance frameworks, and limited interoperability. The researchers literally used the phrase “absence of governance” as one of the defining characteristics.

We suffer from what experts call “pilot disease.” A donor funds a digital health project, maybe a tuberculosis hotline or a maternal health tracking system, and it launches with great fanfare. It stays small. It never scales. When the donor funding ends, the system collapses. According to several studies I reviewed, this pattern repeats constantly across Nigerian states.

Yes, infrastructure is a challenge. Rural areas often have only 2G connectivity or no internet at all. Out-of-pocket health spending is still 74.7% of total health expenditure, leaving little public investment for digital systems.

But infrastructure isn’t the root cause. Even in Lagos, Abuja, and Port Harcourt, cities with good connectivity and well-resourced private hospital systems don’t connect. Why? Because no policy requires them to.

I know there’s hope, though. The Federal Ministry of Health launched the National Digital Health Initiative (NDHI) to create a framework for interoperable electronic medical records across Nigeria. The technology architecture exists. Multiple states are implementing digital health systems. FHIR is part of the national strategy.

But this is very crucial in the sense that if the standards stay optional instead of mandatory, states can choose whether to follow national guidelines, and if there’s no strong enforcement authority, Nigeria will keep having fragmented systems. We’ll keep seeing pilot projects that don’t scale. Patients will keep suffering because their medical information doesn’t follow them.

The lesson: even with limited resources, policy decides whether systems connect or stay siloed.

Case Study 5: Kenya has the technology but not the coordination.

Kenya is often held up as an African digital health success story, and in many ways it is.

The country adopted DHIS2 (District Health Information Software 2), transforming Kenya’s health information from paper-based chaos to a national digital system. Kenya became a model for the World Health Organization’s eHealth strategy for the Africa region. The country literally pioneered mobile health (mHealth) innovations that the rest of the world is now copying.

But Kenyan health informaticists have a term for what still happens despite this progress, “e-chaos.”

At a Digital Health Convergence Workshop in 2024, stakeholders identified three defining features of Kenya’s digital health landscape:

1. Significant fragmentation and poorly coordinated implementation
2. Lack of clear frameworks for standards and interoperability
3. Stakeholder misalignment

In other words, even with DHIS2 in place, systems remain fragmented.

What works: In September 2023, Kenya launched the Electronic Community Health Information System (eCHIS), which uses FHIR to automatically transfer community health worker data to the national DHIS2 system. Where it’s deployed and where the FHIR integration is enforced, it works beautifully. Community health workers enter data once, and it flows automatically into the national system.

What doesn’t work: multiple uncoordinated platforms exist. Different donor fund systems that don’t talk to each other. Manual reporting delays continue. Interoperability gaps remain. Researchers call this “pilotitis”: lots of initiatives, limited scale, and poor coordination.

According to Frontiers in Digital Health research from 2023–2025, the barriers aren’t primarily technical. They’re: poor technological infrastructure (yes, but not the main issue), fragmented governance (this is the big one), and limited digital readiness among health workers.

Kenya’s experience taught me something important: having the right technology standard (FHIR, DHIS2) isn’t enough. Without a policy that requires integration, coordinates implementation, and penalizes fragmentation, technical capability doesn’t lead to real interoperability.

The lesson: adopting the standard and enforcing the standard are two very different problems. The first is technical. The second is about policy.

The Pattern I See Across All Five Countries

After looking at these five case studies, a clear pattern appears:

What I found that works:

1. The technology (HL7 FHIR) exists and is mature
2. It works in Estonia (99% digitization, 20+ years, still operational in 2026)
3. It works in the U.S. VA-DoD system (9 million veterans, ongoing)
4. It works in the NHS App (31 million users)
5. It works in Kenya’s eCHIS (where deployed)
6. The framework exists in Nigeria’s NDHI

What consistently fails:

U.S.: Law passed in 2016, minimally enforced through 2025, enforcement future uncertain.

UK: Standards were voluntary until 2025, now being implemented.

Nigeria: No national authority to mandate anything.

Kenya: Standards exist, but coordination is fragmented.

Everywhere: Systems profit from blocking, face no penalties.

Who pays the price:

U.S.: 2,000 preventable deaths annually from duplicate records.

UK: 31,604 patient harms yearly from medication errors.

Nigeria: Maternal deaths from missing antenatal records (we can’t even count them because our systems don’t track).

Kenya: Disease surveillance failures from fragmented data.

Everywhere: Billions wasted, clinicians burned out, patients frustrated.

What I Think Should Happen (Based on the Evidence)

After all this research, here’s what I believe needs to happen, and these recommendations are based on what actually worked in the case studies I have examined:

1. Make Interoperability Mandatory, Not Optional

From Estonia’s success: All healthcare providers must connect. Non-compliance means you can’t operate. Period.

How to implement:

• Make interoperability a licensing condition for any health facility
• Set hard deadlines for full FHIR compliance
• Loss of certification for non-compliance
• No grandfather clauses, no exceptions

2. Actually Enforce Laws With Real Penalties

From the U.S. failure and VA-DoD success: Federal mandates with accountability work. Unenforced laws don’t.

What this looks like:

• Financial penalties that actually hurt: $10 million first offense, $50 million for repeat violations.
• Public naming of violators
• Executive liability (CEOs held personally accountable like in finance)
• Independent oversight, not vendor self-certification

3. Give Patients Legal Rights to Their Data

From Estonia’s principle: “Data belongs to the data subject.”

What patients should have:

• Legal right to ALL their health data in machine-readable format (FHIR)
• Free of charge, within 24 hours of request
• Complete audit trail showing who accessed their data
• Ability to direct their data to any system or app they choose
• Private right to sue when these rights are violated

4. Fund Inte4. Fund Interoperability as Public Infrastructure’s X-Road and U.S. VA-DoD: Basic data exchange should be government-funded public infrastructure, not a vendor profit center.

Implementation:

• Central government investment in national health information exchange
• Not competing local budgets or vendor upsells
• Open-source platforms where possible
• Vendor-neutral architecture

5. Create En5. Create Enforcement Authorities With Real Poweria and Kenya’s challenges: Without an authority that can enforce, nothing changes.

What this agency needs:

• Technical staff (engineers, not just policy people)
• Independence from industry influence
• Power to audit vendor claims
• Authority to levy fines
• Annual public report card on interoperability

6. Special R6. Special Recommendations for African Countries and Nigeria’s experiences: Africa has a chance to leapfrog legacy mistakes.

How:

• Skip legacy systems entirely. Go mobile-first and FHIR-native from the start.
• Mandate that ALL donor-funded projects must integrate with national platforms
• Reject any digital health funding that creates parallel systems
• Coordinate regionally (African Union Digital Health Strategy)
• Learn from Rwanda’s successes, Kenya’s eCHIS model, and Ghana’s mobile health ID

Why I decided to share this

I started this investigation because I was frustrated. As a nurse, I’ve seen what happens when patient information doesn’t flow. I wanted to understand why such an obvious problem persists, given that we clearly have the technology to solve it.

What I learned changed how I think about digital health entirely.

This isn’t a technology problem. The technology works. Estonia proved it 20 years ago. The VA proved it at American scale. Kenya’s eCHIS proves it can work even in resource-constrained environments.

This is a policy problem. And more specifically, it’s a political courage problem.

Politicians don’t want to upset powerful vendors who lobby and donate to campaigns. Health system executives avoid the hassle and cost of integration when silos are profitable. Donors fund new pilot projects instead of supporting basic infrastructure. And patients, who suffer the consequences, have no organized voice demanding change.

But that can change.

If you’re a policymaker: Look at Estonia. Look at the VA. Look at what the UK finally did in 2025 with mandatory standards. The evidence is clear. The question is whether you have the courage to stand up to powerful vendors and do what’s right.

If you’re a healthcare professional, document every time fragmented systems harm your patients. Report information blocking when you see it. Ask your hospital administrators to explain why they’re not using available interoperability features.

If you’re in tech or health IT, build FHIR-native systems from the start. Make interoperability the default, not an expensive extra. Push back when vendors suggest proprietary lock-in.

If you’re a patient, ask your doctor if your records are accessible to other providers. If they’re not, ask why. Contact your elected representatives. Demand your rights to your data.

If you’re a donor funding digital health in Africa, make integration with national systems a requirement for any funding. No more parallel pilot projects that end when funding stops.

And if you’re a fellow Nigerian or African health professional reading this, we have a chance to do this right. We don’t have to repeat America’s mistakes or Britain’s years of fragmentation. We can learn from Estonia, build on Kenya’s eCHIS successes, and create truly interoperable systems from the ground up.

But only if we demand that policy matches what technology can do.

In Conclusion,

The interoperability problem isn’t technical; it’s about policy. I can say this with confidence after looking at five countries with different cThe technology exists. It’s called HL7 FHIR. It’s been around since 2014. It works in Estonia, the U.S. VA, the NHS App, and Kenya’s eCHIS. The technical problem is solved.is solved.

What changes from country to country is political will.

Every day this policy failure continues:

• Nearly 2,000 Americans die from duplicate record errors
• Over 31,000 people are harmed in the UK from medication errors
• Nigerian mothers deliver without their antenatal records
• Kenyan disease outbreaks go undetected because of fragmented surveillance
• Billions of dollars are wasted globally
• Healthcare workers burn out hunting for information that should transfer automatically

We know what works. The case studies are clear, and the successful models are proven.

What’s needed isn’t new technology. It’s political courage to:

• Enforce the laws already on the books
• Make interoperability mandatory, not voluntary
• Penalize blocking with real financial consequences
• Fund integration as public infrastructure
• Put patients in control of their own data

The technology is ready. The examples are proven. The lives lost are counted.

The only question is whether we, as healthcare professionals, policymakers, technologists, and patients, will demand the political courage to fix it.

Thank you for reading. I’d like to hear your thoughts, especially if you’ve experienced interoperability failures in your own healthcare journey.

Feel free to share this if you think it might help someone understand why their medical records don’t follow them and what we, as a community, can do about it.

I will see you in my next article.

Bye for now.

Esther O.

​