Why Your Interoperability Strategy Is Missing 80% of Care
In the US, the vast majority of patient interactions occur outside of acute care settings. While there are around 33 million hospitalizations each year, this is eclipsed by the more than 66 million behavioral health visits, 119.9 million community health center visits, 2.7 million Medicare beneficiaries receiving home health services, and the 7.3 million Americans utilizing post-acute care services, suggesting that at least four out of five patient interactions take place outside the hospital setting. Post-acute providers, home health agencies, physical therapy, behavioral health organizations, specialty practices and community health centers often carry the bulk of ongoing care long before and after a patient leaves the hospital.
And yet the bulk of interoperability investment (both financial and structural) has flowed to hospitals and physicians.
Consider:
- Unlike hospitals and physician practices, nursing homes were excluded from the Health Information Technology for Economic and Clinical Health (HITECH) Act at its enactment in 2009
- The Promoting Interoperability Program (formerly Meaningful Use) provides incentive payments and requirements mostly for eligible hospitals, critical access hospitals and physician practices.
- Roughly five out of six hospitals are not reliably sharing care summaries with the providers who see patients next.
- Interoperability indices developed by ONC are specifically tracking hospital interoperability progress, leaving post-acute care behind.
While hospital systems received federal incentives to modernize their EHRs and meet interoperability mandates, much of the “last mile” of care was left out. Non-acute and home health providers were expected to coordinate with hospitals without receiving the same capital, infrastructure support, or technical lift.
Forgotten for the longest time, now they’re the most important and expected to modernize overnight, still without a dollar provided. They’re being asked to adopt AI, implement new care models, reduce readmissions, improve outcomes, manage staffing shortages, and prove value in increasingly complex payment models. They’re being told to be interoperable. So, while the incentivized industry has had nearly two decades to prepare and implement, non-acute providers are scrambling to catch up. But many of them lacked the capacity to build the digital foundation hospitals and physicians take for granted.
Non-acute providers are required to coordinate closely with hospitals and physicians, yet operate under significant margin pressure and limited technical resources. Home health agencies are delivering 24/7 care in patients’ homes while navigating severe staffing shortages and minimal IT support. Behavioral health organizations face workforce strain and specialized challenges around privacy. Specialty providers are managing increasing complexity and referral demands. While hospital IT departments debate API strategies and network participation, non-acute care providers are often starting from the basics.
Compounding the Challenge, the majority of health systems and hospitals still do not support true standards-based, interoperable transitions of care. Many continue to rely on legacy portal infrastructure for their post-acute partners to access — often at the post-acute provider’s expense. The burden of connection is pushed downstream to the organizations least equipped to carry it.
These organizations aren’t debating network strategy; they’re working through foundational questions. What does modern interoperability mean for their organization, from technology and workflows to investment and privacy? What do their EHR vendors actually support? Where do they begin? And critically, do they have the staff capacity to take this on when AI and other priorities are already competing for the same limited resources?
Interoperability conversations often assume a level of infrastructure, both technical and administrative, that simply doesn’t exist across much of the care continuum. Before advanced analytics, before AI, before care coordination dashboards, there is a fundamental need for information that can move reliably.
Until the last mile is connected, healthcare transformation remains incomplete.
Where to Begin
Uncertainty is understandable, and it’s exactly where most non-acute organizations find themselves. Closing the last-mile gap doesn’t start with transformation; it starts with infrastructure. Here’s what that looks like in practice.
Step 1: Get Connected
Connectivity is the first and most urgent requirement.
Nearly three fourths (71%) of post-acute, home health, behavioral health, and specialty providers are not fully connected to their referral sources. EHR systems may exist, but they are not reliably exchanging data across settings. Information often arrives late, incomplete, or through manual processes like fax and portal logins. This is not a non-acute problem to solve. The responsibility lies with the health systems originating from the data.
So first, we need to get these systems connected. We do that by auditing referral pathways, prioritizing high-volume partners, and replacing fragmented fax, portal, and point-to-point connections with unified healthcare communication infrastructure that integrates once into the EHR and supports exchange across every required channel.
Once the full care continuum can send and receive information reliably, we can scale interoperability to its full potential.
Step 2: Get Information Flowing
Connectivity alone is not enough. Data must move efficiently and in usable formats, but this is where post-acute providers often hit a wall. Health systems and their technology frequently require providers to log into separate portals to retrieve records, a dynamic that is largely outside the post-acute provider’s control. Advocacy matters here, and so does choosing partners and vendors who prioritize direct EHR delivery over portal access.
Where providers do have agency: standardizing how discharge summaries, medication lists, and care plans are received and reconciled once they arrive; automating routing to the appropriate teams; reducing duplicate data entry through structured exchange; and establishing clear processes for reviewing and acting on incoming information quickly.
When information flows, even incrementally, manual re-entry decreases, phone calls and follow-up faxes decline, and staff time shifts back to patients. You can’t optimize what you can’t access, so push for exchange that is reliable, fast, and embedded in daily operations, and hold health system partners accountable for making that possible.
Step 3: Then Layer in AI and Advanced Tools
AI requires clean, connected, clinically verified, accessible data. It cannot compensate for missing summaries, delayed referrals, or disconnected systems. AI is an amplifier.
In practice, layering new technology should look like:
- AI prioritizing referrals once they are digitally received.
- Analytics identifying care gaps once structured data is consistently flowing.
- Automated quality reporting once data exchange is reliable.
- Predictive tools that support staffing allocation after operational workflows are digitized.
If the system is disconnected, it amplifies inefficiency. If the system is connected, it amplifies impact.
You Are Not Forgotten
Interoperability strategy that stops at the hospital is incomplete. If post-acute, home health, behavioral health, specialty, and community-based providers cannot reliably exchange information, the system remains fragmented.
We built Kno2 specifically to solve this gap. It was not easy, but it was necessary. Healthcare communication has to be built on the right infrastructure, allowing providers to connect once and communicate across channels, networks, and care settings. The next phase of interoperability progress will not be driven by the 20% of care inside hospital walls, but by the 80% happening beyond them.
