TEFCA is live: What’s next?

The EHR Association explains how TEFCA’s launch advances healthcare connectivity and access to public healthcare.

The ability for healthcare providers to appropriately connect with and securely share electronic health information with network stakeholders that are managing patient care is critical to support care coordination, continuity, and improved clinical decision support.

It is also crucial for supporting the patient’s ability to fully access their health record and enabling authorized parties to access any relevant and appropriate information for other purposes such as healthcare operations, benefits determination, public health and other authorized purposes.

On Dec. 12, 2023, a major step was taken toward the realization of this goal when the Office of the National Coordinator for Health IT announced the first five designated Qualified Health Information Networks (QHINs) under the Trusted Exchange Framework and Common Agreement (TEFCA). In February 2024, two additional networks were designated as QHINs, and two other networks are actively working to become QHINs.

Thus, the stage is set to begin operationalizing the 21st Century Cures Act requirement to develop or support a national trusted exchange framework and advance national electronic health information exchange beyond the current capabilities of CommonWell and Carequality.

With many EHR Association members already enabling their clients to connect to local, regional and national networks as part of these nine QHINs, the doors to TEFCA are officially open. The question now is, “What’s next?” 

TEFCA’s origin

TEFCA was created under the auspices of the 21st Century Cures Act with the publication of initial documents, including the Common Agreement, QHIN technical framework and various standard operating procedures, beginning in January 2022.

At its core, TEFCA consists of a set of non-binding foundational principles for health information exchange and the Common Agreement, which is a contract establishing the technical infrastructure model and governing approach for different QHINs to securely share health information under commonly agreed-upon rules. The QHIN technical framework and various standard operating procedures provide the technical and operational underpinnings to further define and manage the exchange purposes, standards and procedures.

TEFCA’s goal is to create a flexible structure that enables stakeholders – ambulatory practices, hospitals, health centers, payers, HIT developers, federal government agencies, public health agencies and individuals – to benefit through improved access to health information by creating a network of networks across which the QHINs would facilitate the sharing of relevant information.

Progress to date

Several key milestones have been reached since TEFCA’s creation, beginning with establishing the initial Common Agreement, QHIN technical framework and various standard operating procedures. In February 2023, the first six QHIN candidates – CommonWell Health Alliance, eHealth Exchange, Epic Nexus, Health Gorilla, Kno2 and Konza – were approved for the testing and project plan phase. A seventh candidate, MedAllies, was added in May 2023. 

Since then, eHealth Exchange, Epic Nexus, Health Gorilla, Konza and MedAllies were formally designated as QHINs in December 2023, while CommonWell and Kno2 were designated in February. Applications also have also been submitted by eCW and Surescripts, and they are progressing to become a designated QHIN in the future.

At the same time, new versions of the Common Agreement, QHIN technical framework and various standard operating procedures were made available for public review in late January addressing a variety of topics, including the expansion of use cases and the ability to advance interoperability through facilitated FHIR-based data sharing.

Live transactions are already occurring under TEFCA, including requests from individual access services (IAS) providers. As more networks are designated and sign up more participants, TEFCA has the potential to rapidly gain momentum.

What’s next

A common question is what TEFCA provides that the established national networks, Carequality and CommonWell, do not, particularly as the primary initial interactions will be queries for documents under treatment – which is already done extensively through those established networks.

While the exchange will initially address a similar scope, the goal is to advance substantially beyond that capability. For example, IAS will be included from the outset. Further, while the initial timeline indicated IAS would start six months into the exchange process, they are already supported by QHINs. Work is also underway to address public health and healthcare operations, and to begin FHIR-based document and data exchange. 

TEFCA can provide key capabilities to advance public health use cases – the importance of which has escalated after the COVID-19 pandemic – by further improving access to a more complete patient record. This includes appropriate de-identification when required.

Further, advances in FHIR-based exchange expand opportunities beyond document exchange – whether based on the IHE document exchange standards or FHIR document exchange methods – and move from element-level data access to data sets and bulk data into data-level exchange. All of this would take place under a common agreement or common trust framework, whether facilitated (for example, QHINs enable identification of the participants where the patient has data, but the individual participants’ FHIR infrastructures directly interact with the data sources) or brokered (for example, QHINs also manage queries and collate data on behalf of the requester) as appropriate.

Efforts are also underway to define the scope of healthcare operations and enable key use cases to improve provider-payer interactions. With the efforts by HL7 Da Vinci to define FHIR-based implementation guides to advance these interactions, we should start to see TEFCA utilize these capabilities and others to take advantage of the benefits of a trusted exchange framework.

While Carequality and CommonWell can provide some of these capabilities, TEFCA was established to address them as a prerequisite, thereby enabling a national framework that covers all use cases across all stakeholders. This permits the achievement of what is the equivalent of the national telephone network, where everybody can share data with everybody. 

As the deployment unfolds, the Recognized Coordinating Committee and ONC are also working on the next versions of the common agreement and standard operating procedures, based on experiences to date and in preparation for the introduction of FHIR-based data exchange.

Connect is the answer

This year will be busy as participation ramps up, along with advancing the common agreement and standard operating procedures for additional use cases. Further, not all networks are connected under TEFCA, nor is everybody that is part of a network designated as a QHIN.

This raises several questions. What should providers, IT developers and other stakeholders do next? If they’re already connected to Carequality, should they shift now? Where do they start if they’re not connected to a network that is or is about to be connected to a QHIN?

These questions are best addressed with IT suppliers, the networks they support and the networks they’re already part of to understand their roadmap to TEFCA and therefore the best path forward. Also, consider that current Carequality participants who connect to TEFCA will likely remain part of Carequality, thus ensuring their existing connections remain in place while TEFCA is ramping up. However, those who join TEFCA directly might consider skipping Carequality if they have sufficient immediate and future connectivity to meet their goals.

The best step providers can take now to prepare for TEFCA is to connect with either a designated or applicant QHIN or a network that intends to participate in either QHIN in the future. Doing so enables the patient record to grow now and then progress into TEFCA to take advantage of new and further expanded capabilities.

Final thoughts

As data flow expands and volumes rapidly increase, data usability will be one of the key subjects of the next set of questions that providers, IT developers and other stakeholders will be asking. These include how can we improve the quality of the data? What is the right amount of data, short of “everything always”? How can we ensure predictable searches for data so I get what I expect?

These and other data usability questions are front and center in The Sequoia Project’s Interoperability Matters data usability initiatives. The EHR Association supports these initiatives because they seek to improve the quality and consistency of data content, whether that be a document, individual data in a data set or part of bulk data exchange.

Stephanie Jamison works for Greenway Health and is the executive committee chair and is the public policy leadership workgroup vice chair for the EHR Association. Hans Buitendijk works for Oracle Health and is executive committee ex-officio member and public health workgroup chair for EHRA. Also contributing to this article were Josh Mast (Oracle Health), chair of the public policy leadership workgroup; Cherie Holmes-Henry (NextGen Healthcare), executive committee member; and Toni Wilken (MEDITECH), chair of the quality measures workgroup.

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