---
title: "HIT Perspectives June 2026: Interop as Infrastructure"
description: Explore how healthcare organizations can overcome scalability challenges by building trust through identity, consent, & security infrastructure for scalable data exchange.
image: https://info.pocp.com/hubfs/Untitled%20design%20(31)-modified.png
---
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# Optimizing Health IT. For Good
Point-of-Care Partners delivers deep expertise through a 360-degree perspective to help organizations navigate complexity and drive meaningful progress.
# HIT Perspectives
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### Subscribe
#### HIT Perspectives – June 2026
# Trust at Scale: A Bigger Challenge Than Expected
* [](https://www.linkedin.com/in/vcandelora/)By [Janice Reese](https://www.linkedin.com/in/networkpdf/), Senior Consultant & Program Manager, FHIR at Scale Taskforce (FAST)*
### Quick Summary
- **Shift to trust:** Healthcare’s interoperability challenge is shifting from connectivity to trust at scale.
- **API limits:** Application programming interfaces (APIs) alone cannot solve identity, consent, endpoint discovery, onboarding, or reusable authorization challenges.
- **Manual bottlenecks:** Manual trust processes that worked for limited exchange are becoming major bottlenecks as national-scale interoperability expands.
- **Critical infrastructure:** Identity matching, computable consent, security, and national directories are emerging as critical infrastructure layers for scalable exchange.
- **AI depends on trust:** Artificial intelligence (AI) and automation initiatives depend on trusted governance, secure routing, reliable authorization, and accurate data provenance to scale safely.
- **FAST’s role:** The FHIR At Scale Taskforce (*FAST*) is helping healthcare address foundational trust and governance gaps before they become larger operational risks.
- **Act now:** Organizations should begin assessing their interoperability readiness now, including technology, workflows, governance, staffing, and operational maturity.
Moving data is far less difficult than it was a few years ago. Fast Healthcare Interoperability Resources® (FHIR®) APIs are widespread, the Trusted Exchange Framework and Common Agreement has established a national framework for exchange, and Centers for Medicare and Medicaid mandates have accelerated modernization across payers and providers. The industry’s challenge is no longer whether systems can connect, but whether trust can be established once and reused across the ecosystem.
APIs are helping solve connectivity but don’t solve identity across networks, computable consent, endpoint discovery, automated onboarding, reusable authorization, or policy enforcement. Those gaps are why work within [HL7’s *FAST*](https://confluence.hl7.org/spaces/FAST/pages/130482368/FHIR+at+Scale+Taskforce+FAST+Home) Identity, Security, Consent, and National Directory is drawing increasing attention. These are no longer future-state architectural debates; they are becoming the infrastructure required for interoperability at scale.
### APIs Are Solving Connectivity but Not Trust
Healthcare is moving beyond isolated integrations toward an environment in which organizations that have never worked together must establish trust quickly and reliably. Historically, that trust was created through manual onboarding, credential reviews, security questionnaires, static client credentials, and organization-specific agreements. That model works for a small number of partners but does not scale to thousands of endpoints. As recent FAST Security discussions have highlighted, the “human step” has become the enemy of scale.
### Why Scale Changes Everything
At smaller scales, organizations can compensate for a fragmented trust infrastructure with manual workarounds. At the national scale, those workarounds become bottlenecks. Payers, providers, qualified health information networks, pharmacies, public health agencies, digital health apps, and AI-enabled platforms need to consistently verify identities, automate onboarding, dynamically discover endpoints, enforce real-time consent, and route transactions securely across networks. That requires infrastructure, not just APIs. Other industries solved versions of this problem years ago by building reusable trust models in which identity and authorization are verified once and honored across ecosystems.
### Identity: Healthcare Has Built Matching Systems, Not Identity Infrastructure
Healthcare has invested heavily in patient matching and enterprise identity management but matching and identity are not the same thing. Matching is probabilistic; identity is a matter of trust. Many organizations still rely on demographic data such as name, address, date of birth, and phone number to establish identity across systems, an approach that becomes fragile as exchange expands across networks and consumer-facing applications. Work underway within [*FAST* Identity](https://confluence.hl7.org/spaces/FAST/pages/358254757/Interoperable+Digital+Identity+and+Patient+Matching?src=contextnavpagetreemode) is helping to move healthcare beyond demographic matching toward reusable digital trust models aligned with the CARIN Alliance digital trust framework and National Institute of Standards and Technology assurance models. Without a scalable identity infrastructure, interoperability remains fragile no matter how many APIs are deployed.
### Consent: The Governance Layer Healthcare Cannot Ignore
Consent is one of the most underappreciated barriers to trusted interoperability at scale. Too often, it is still treated as a static compliance artifact—a paper form, scanned PDF, checkbox, or one-time registration authorization. That model breaks down when data flows continuously across organizations, applications, networks, and delegated relationships, especially for sensitive information such as behavioral health, reproductive health, substance use disorder treatment, adolescent records, and state-specific privacy requirements. Work underway within [*FAST* Consent](https://confluence.hl7.org/spaces/FAST/pages/358254755/Consent+Management) treats consent as a computable, distributed infrastructure that supports real-time enforcement, delegation, revocation, auditability, discoverability, and event-driven updates. Consent must move with the data.
## Security: Authentication Alone Does Not Create Trust
SMART on FHIR and OAuth solved important application authorization challenges, but they were not designed to create scalable trust across a national healthcare ecosystem. Many organizations still depend on manual onboarding, bilateral agreements, static client credentials, email-based registration, and organization-by-organization credentialing. Work underway within [*FAST* Security](https://confluence.hl7.org/spaces/FAST/pages/358254847/Security+for+Scalable+Registration+Authorization+and+Authentication) focuses on reusable trust relationships, certificate-based identity, automated registration, policy-driven authorization, and cryptographic verification across trust communities. The goal is to establish trust once and reuse it across networks.
## Directories Are Becoming Routing Infrastructure
Even when identity, consent, and authorization are in place, organizations still need to know where to route requests. Endpoint discovery remains immature across much of healthcare, making it difficult to determine which endpoint should receive a request, whether it is operational, what capabilities it supports, and how routing should occur across intermediary networks. This is why workarounds for [*FAST* National Directory](https://confluence.hl7.org/spaces/FAST/pages/358255046/National+Healthcare+Directory) and broader endpoint discovery frameworks matter. Directories are becoming the routing infrastructure for scalable exchange.
### AI and Automation Depend on Trust Infrastructure
Much of healthcare’s innovation conversation focuses on AI, automation, predictive analytics, and intelligent workflows. None of those capabilities scales successfully without a trusted infrastructure beneath them. AI systems require trusted identity, reliable provenance, consistent authorization, computable consent, accurate routing, and secure automation. Without those layers, organizations risk building increasingly sophisticated systems on fragmented governance and inconsistent trust models.
### The Next Phase of Infrastructure Building
The next phase of interoperability maturity will depend less on whether organizations can exchange data and more on whether they can operationalize the foundational infrastructure layers required to support trusted exchange at scale, including identity, security, consent, and discoverability.
That is why the work happening within *FAST* has become increasingly important. As the program management organization for FAST, Point-of-Care Partners (POCP) works alongside industry leaders, policymakers, payers, providers, health information technology developers, and standards organizations helping to advance scalable solutions for trust, security, consent management, identity, and national directory infrastructure.
POCP strongly encourages organizations to participate in collaborative communities like *FAST*, where the industry is actively working to solve the foundational challenges required for interoperability on a scale.
At the same time, operationalizing identity, security, consent, and trust frameworks within an organization’s existing technology, workflows, governance structures, and staffing models requires an objective assessment of current capabilities, gaps, and readiness for change.
In our strategic consulting work, POCP helps organizations navigate these challenges every day by aligning interoperability strategy, standards, governance, operations, and implementation realities to support scalable, trusted exchange, starting with an objective look at where an organization is currently operating, from tech stack and processes to staff skills and education.
To discuss your organization’s interoperability challenges, opportunities, and readiness for scalable trust infrastructure, [contact POCP](https://www.pocp.com/contact/?utm_source=chatgpt.com).
***Additional Reads***
[The “Human Step” Is the Enemy of Scale](https://www.linkedin.com/pulse/human-step-enemy-scale-why-fast-security-digital-trust-janice-reese-pqzoc)
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