The Standard

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.

The HL7® FHIR® at Scale Taskforce (FAST) continues to translate national interoperability policy into implementable, real-world infrastructure. This month marks several major milestones, including the opening of the FAST Consent Ballot, the official publication of FAST Identity STU 2 and FAST Security STU 2, and continued progress on FAST National Directory toward STU 2. This reinforces the growing momentum toward CMS-Aligned Networks powered by FAST. 

These advances demonstrate how standards, trust frameworks, directory infrastructure and testing at scale converge to support scalable, secure and interoperable data exchange across the healthcare ecosystem. 

FAST Consent Ballot: Advancing Scalable, Network-Ready Consent 

The FAST Consent Implementation Guide (Edition 1 – US Realm) has entered formal HL7 balloting, providing the industry with a practical, interoperable approach to consent management at scale. 

The guide is designed to support: 

• Computable and portable consent representations across organizational and network boundaries 

• Subscription-based workflows for consent updates and downstream disclosures 

• Alignment with FAST Identity, FAST Security, and FAST Directory infrastructure 

• Use cases spanning payer-to-payer exchange, provider workflows, HIEs, and consumer-mediated access 

The HL7 FHIR at Scale Taskforce (FAST) is going international! As part of our mission to accelerate FHIR adoption and interoperability around the globe, FAST is taking its work beyond the U.S. to engage with the international health IT community. 

For the first time ever, FAST will be hosting a dedicated track at the HL7 FHIR Connectathon in Madrid, featuring two of our most critical and widely applicable Implementation Guides (IGs): 

🔐 FAST Security - https://build.fhir.org/ig/HL7/fhir-udap-security-ig/branches/main/ 
🆔 FAST Identity - https://build.fhir.org/ig/HL7/fhir-identity-matching-ig/ 

While these IGs were originally developed under the U.S. ONC's efforts to advance FHIR adoption, their guidance is intentionally broad and applicable globally. In fact, we're in the process of transitioning them to universal realm status, and your international input is vital. 

Why Participate? 
🌍 Help shape these key IGs to meet global needs 
🧪 Test and validate implementation with FAST experts
📚 Attend deep-dive breakout sessions focused on Security and Identity
🚀 Prepare for the future – FAST Security is a required standard for TEFCA FHIR exchange starting January 1, 2026 in the U.S. 

As the Trusted Exchange Framework and Common Agreement (TEFCA) moves ahead for FHIR usage within the framework, the use of the HL7 FAST UDAP Security for Scalable Registration, Authentication and Authorization FHIR IG (FAST Security) is becoming more important to the security framework for FHIR within the US and in other countries. As part of our mission, the FHIR At Scale Taskforce (FAST) wants to help people get ready for the TEFCA January 1, 2026, deadline to have Fast Security implemented for FHIR Exchange over TEFCA.

To help implementers, CISOs, and anyone interested in FHIR on TEFCA out, FAST is holding a 1-day event to introduce the Security IG and how TEFCA will use it and information about general TEFCA security, Security IG testing, and other aspects. This event is FREE on January 13, 2025, right before the FHIR Connectathon. If you’re interested in FHIR on TEFCA or want to know the latest in FHIR OAuth security, you can sign up at: https://info.hl7.org/fast-security

The latest FAST Focus webinar provided a comprehensive update on the progress and scope of the FAST Consent project, an initiative pivotal to streamlining data exchange in health IT. This quarterly series aims to engage the community, share updates, and encourage participation in ongoing FASTprojects. Below, we delve into the key takeaways from the session, with a spotlight on the objectives and contributions  

The FAST Consent Project: An Overview 

Consent management in healthcare is a complex issue that requires innovative solutions to manage and transmit consent records at scale. The FAST Consent project emerged in response to these challenges, focusing on how to make consent management effective across a diverse and multi-faceted ecosystem. Project leads—including Durwin Day, Mohammad Jafari, Kevin Day, Maidul Islam, Sam Schifman, and Jean Duteau—are spearheading efforts to define scalable consent handling strategies that align with both technical and legal requirements. 

As healthcare's digital transformation accelerates and data fluidity improves, the need to ensure patients maintain control over their health data becomes more urgent. While better interoperability brings many benefits, it also raises significant challenges around consent. The key question is: how do we efficiently manage patient consent to ensure privacy preferences are respected at scale, across multiple organizations and systems? 

The FHIR at Scale Taskforce (FAST), is focused on identifying scalability gaps, defining solutions to address current barriers, and identifying needed infrastructure for scalable HL7 Fast Healthcare Interoperability Resources (FHIR®) solutions so taking on consent as a use case was a natural evolution. 

The upcoming FAST Focus Webinar on November 7, 2024, will delve into this critical topic, offering stakeholders valuable insights into the FAST Consent team's efforts to develop a standardized framework for consent management. The webinar will provide an update on their progress, highlighting the collaborative work that has shaped the project’s evolution, as well as specific use cases that are central to its scope. 

Health Level Seven International (HL7^®), the leading global standards-development organization dedicated to improving how healthcare information is shared, is excited to announce it has assumed stewardship of the open source FHIR^® Shorthand (FSH) tools from MITRE. This strategic transition will ensure the long-term sustainability and growth of these essential tools, which simplify and speed up the creation of HL7 Fast Healthcare Interoperability Resources (FHIR^®) implementation guides that define how healthcare data should be structured and shared between systems to ensure smooth and accurate data exchange.

HL7 FHIR Shorthand (FSH) is a streamlined, text-based tool that enables healthcare IT stakeholders to create implementation guides, or "blueprints," for sharing critical health information such as patient records, lab results, treatments across different systems, and much more. Developed by MITRE in 2020, the FSH standard has quickly become an essential tool in hundreds of healthcare projects worldwide, helping to simplify the process of developing systems that support better coordination and improved patient outcomes.

The FHIR at Scale Taskforce (FAST) community has been at the forefront of shaping the future of healthcare interoperability. By working closely with the FHIR community and other FHIR Accelerators, FAST is building the framework for a robust FHIR infrastructure that supports the scalability of FHIR solutions across the healthcare ecosystem. Today, we are excited to announce an important leadership transition as we continue this vital work.

A New Opportunity for Dana Marcelonis

Dana Marcelonis, who has been a cornerstone of FAST as our Program Manager, will be transitioning to a new role at Point-of-Care Partners, where she will provide program support for the Coalition for Health AI (CHAI) project. Dana’s expertise, dedication, and leadership have been instrumental in guiding FAST’s efforts, and her impact on our work cannot be overstated. While Dana managed both roles admirably, the increasing demands of these projects have made it necessary to have a dedicated resource for each. Dana will continue to support Janice and the team through November to ensure a smooth transition.

August 28 Webinar Features Recent Updates Direct from Federal Officials

Are you looking for guidance and insight as you plan for 2025? If so, plan to attend this month’s Health Level Seven (HL7^®) Da Vinci Project Community Roundtable, which features special guests from the Assistant Secretary for Technology Policy (ASTP) office, formerly known as the Office of the National Coordinator for Health Information Technology (ONC). ASTP presenters will highlight why the Trusted Exchange Framework and Common Agreement^TM (TEFCA^TM) is important and share recent updates to the program, including implementation, long term plans, education and outreach, and building trust.

In ASTP’s second segment, testing and adoption efforts will be discussed, covering TEFCA’s HL7 Fast Healthcare Interoperability Resources (FHIR^®) Roadmap, and ASTP’s new TEFCA Payer/Provider 10x10 Coalition. ASTP will provide an overview of the 10x10 and discuss why providers and payers should participate. They will also discuss resources available and the interplay of the 10x10 with Da Vinci.  

The session concludes with the Da Vinci PMO sharing themes and perspectives from its membership on the Health Data, Technology, and Interoperability: Patient Engagement, Information Sharing, and Public Health Interoperability (HTI-2) proposed rule.