The Standard

Healthcare interoperability has reached an inflection point.

In 2026, success is no longer defined by the presence of APIs but by the ability tooperate securely, consistently, and at scale across networks, organizations, and increasingly, across borders.

This shift reframes interoperability as something far more consequential:
a shared trust problem spanning cybersecurity, financial sustainability, and patient safety.

At the center of this transformation is FAST Security, emerging not simply as a technical specification, but as thefoundational trust layer for a global healthcare ecosystem.

Interoperability Is Now a Cybersecurity Surface

As healthcare exchange accelerates—payer-to-payer data sharing, automated prior authorization, and network-based access—organizations are no longer just exposing APIs.

They are expanding an identity and authorization attack surface.

Each new connection introduces:

• Additional credentials to manage
• Increasingly complex authorization logic
• More exceptions and edge cases
• Greater exposure to misconfiguration and attack

This is not a scaling API problem; it is a scaling trust problem.

FAST Security directly addresses this by standardizing how trust is established, enforced, and audited across organizational boundaries.

FAST Security as the Foundation of Trust Architecture

FAST Security is not designed to operate in isolation.

It provides the core trust workflows—authentication, authorization, and onboarding—that enable the broader FAST ecosystem:

• FAST Identity → Who is trusted
• FAST Security → How trust is enforced
• FAST Consent → What is permitted
• FAST Directory → Where trust is discovered

Together, these form a layered, reusable trust architecture aligned with modern interoperability demands.

This architecture allows trust to move from fragmented, one-off integrations to repeatable, scalable infrastructure.

How States Can Move From Fragmented Programs to Shared, Scalable Infrastructure Using FAST

The CMS Aligned Networks Pledge marks a clear inflection point in federal health IT policy. For the first time, Centers for Medicare & Medicaid Services (CMS) is not simply setting compliance requirements for individual programs—it is asking the healthcare ecosystem to operate as connected networks, capable of secure, real-time, standards-based data exchange across payers, providers, public health and patients.

For states, this shift is significant.

States are no longer just one participant among many. They are increasingly the anchor for trust, identity, consent and directory infrastructure that enable CMS-aligned networks to function at scale. Medicaid programs, state CIO offices and HIEs sit at the intersection of policy, operations and technology. The CMS Aligned Networks Pledge makes that role explicit.

This blog explains:

1. What the CMS Aligned Networks Pledge really changes for states
2. Why traditional, program-by-program approaches will not scale
3. How the  HL7® FHIR® at Scale Taskforce (FAST)  provides the infrastructure states can reuse across initiatives
4. How states can leverage existing systems and vendors without starting over

The CMS Aligned Networks Pledge: A Shift from Programs to Infrastructure

Historically, CMS initiatives have been implemented as discrete programs:

• A new reporting requirement
• A new API mandate
• A new exchange use case
• Trusted digital identity and patient matching
• Scalable security and partner onboarding
• Computable, portable consent
• Authoritative directories for endpoint discovery

The CMS Aligned Networks Pledge represents a different expectation.

CMS is signaling that future interoperability depends on shared infrastructure capabilities, including:

• Trusted digital identity and patient matching
• Scalable security and partner onboarding
• Computable, portable consent
• Authoritative directories for endpoint discovery

These are not features of a single application. They are ecosystem functions.

For states, this means success is no longer measured by whether a single system goes live, but by whether multiple programs can reuse the same trust and exchange foundations.

Those of us working across health policy, technology, and standards are reimagining a system where individuals experience better outcomes, lower costs, and greater trust in how their health information is used and shared.

At HL7® International, a global standards development organization with members and affiliates in more than 50 countries, we are meeting our challenge head-on through collaboration and innovation. The HL7® FHIR® at Scale Taskforce (FAST) Accelerator takes that mission further by tackling the hard problems of scalability: Identity, Security, Consent, and National Directory services. These components are the backbone that supports the CMS Health Tech Ecosystem and Aligned Networks Pledge.

Paired with the Da Vinci Project, which applies FHIR to payer–provider workflows like prior authorization, clinical data exchange, payer data exchange, and patient cost transparency. HL7 is aligning infrastructure with real-world use cases. Da Vinci has recognized the value of FAST standards by selecting FAST Security as part of their security recommendations in their core health record exchange (HRex) specifications, showing a convergency across the ecosystem.

Where Sequoia’s RCE Role Elevates the Work: TEFCA as the National Trust Layer

FAST isn’t building infrastructure in a vacuum. Its work aligns with the Trusted Exchange Framework and Common Agreement (TEFCA), led by The Sequoia Project as the Recognized Coordinating Entity (RCE) for ASTP/ONC. TEFCA is a national framework for the secure and trusted exchange of clinical data across networks.