Unlocking healthcare’s interoperability potential: The TEFCA journey

TEFCA promises seamless health data exchange across providers, but will it deliver the dream of nationwide interoperability?

This article is part of the August/September 2023 COVERstory.

Interoperability – the easy exchange of healthcare information – has been on the wish list of many for three decades, from way back when community health information networks were Holy Grail for moving data between providers.

There have been no such easy solutions over the years. Despite nudges from federal agencies and the industry acknowledging the shortcomings caused by lack of interoperability, there’s still a long road ahead for data exchange. Many are pinning their hopes on the Trusted Exchange Framework and Common Agreement (TEFCA) to make widespread interoperability a reality.

What’s the dream? For Micky Tripathi, it means enabling connectivity analogous to that provided by the nation’s cell phone network. Whether you get your service from Verizon, AT&T or any other provider, cell phone users are able to communicate and share pictures or files with anyone else in the country, no matter which service provider they’re using.

“For the majority of us, what we do on a day-to-day basis, it just works – it’s all connected on the back end, and we don’t have to worry about that,” says Tripathi, the national coordinator for health information technology. “You have the experience of a single network, even though it involves multiple networks. There’s wide agreement on technical specifications, which work to keep it going so users find it really easy.”

But before achieving ubiquitous nationwide interoperability, a devilish array of details and challenges are yet to be solved. These include bridging the last mile of connectivity to some organizations (particularly those that are under-resourced); increasing the usability of patient data to ensure it can be effectively used by people within their workflows; simplifying the complexity and duplicity of the current environment; and more.

Indeed, it may be another decade before the industry can gain the full benefits from pervasive interoperability, some experts believe.

TEFCA gets going

But TEFCA is being framed as a crucial step that will unlock a single, common nationwide approach to enable a range of healthcare information to flow to a wider array of entities in the healthcare ecosystem. It was announced in early 2022 as part of an effort to complete a requirement of the 21st Century Cures Act, to establish a clear infrastructure model and governing approach for nationwide health information exchange.

The overall goal of TEFCA is “to establish a universal floor for interoperability across the country,” according to the Office of the National Coordinator for Health Information Technology. “The Common Agreement will establish the infrastructure model and governing approach for users in different networks to securely share basic clinical information with each other — all under commonly agreed-to expectations and rules, and regardless of which network they happen to be in.”

Further, ONC describes the Trusted Exchange Framework as including “a common set of non-binding, foundational principles for trust policies and practices that can help facilitate exchange among HINs.”

TEFCA is intended to be more than theoretical. It’s to be actualized by Qualified Health Information Networks (QHINs) – a network of organizations working together to share data. QHINs will connect directly to each other to ensure interoperability between the networks they represent.

In the original design, QHINs will provide connectivity services, including master patient index (whether federated or centralized); record locator service (RLS); broadcast and directed queries; and the return of electronic health information in response to requests. Participants in the nationwide network “connect to each other through the QHIN, and they access organizations not included in their QHIN through QHIN-to-QHIN connectivity.” Participants can include health information networks, EHR vendors and other types of organizations.

Finally, ONC has designated The Sequoia Project as the “recognized coordinating entity,” which gives it latitude to develop, update, implement and maintain the common agreement. As part of its role, Sequoia also sought applications from organizations wanting to be QHINs,

Earlier this year, ONC announced that six organizations had been approved to implement TEFCA as prospective QHINs – these include CommonWell Health Alliance, eHealth Exchange, Epic TEFCA Interoperability Services, Health Gorilla, Kno2 and KONZA. In May, MedAllies became the seventh organization approved to seek to become a QHIN.

Progress so far

TEFCA aims to accelerate interoperability now that the industry has made rapid advances in digitization over the last dozen years, Tripathi says. Federal agencies prioritized the implementation of electronic health records to get the health industry off paper records, and now that data exchange technology has advanced in recent years, “it opens up more network-based capabilities, and specific kinds of approaches through FHIR-based (application programming interfaces), which aids ease of use.

TEFCA also aims to build off the recent experiences of information exchange initiatives like Carequality and CommonWell, which enable some degree of access to patient records by providers who participate in them.

These networks have connected thousands of providers and now exchange hundreds of millions of records per month, says Mariann Yeager, CEO of the Sequoia Project. For purposes of benchmarking that growth, Carequality, a national-level, common interoperability framework to enable health information exchange between and among health information networks, took nearly four years before achieving one billion total clinical documents exchanged in early 2020.

Still, the capability of processes to efficiently and effectively exchange information has typically lagged behind technical abilities, and that’s what TEFCA intends to address, Tripathi says.

“Just because the pipes are there doesn’t mean everyone is using them,” he explains. “We need to change the culture of information sharing so people have the posture that information should be shared. A lot of that depends on where it is in the priority stack. The entire healthcare system is under a lot of stress, and we need to move (interoperability) up the priority stack. There’s still a big gap between what we can do and what we’ve been able to accomplish, and a lot depends on what is happening in the last inch of connectivity. In too many cases today, you know the electronic connections exist but the information isn’t getting where it needs to be.”

Developing or optimizing those processes for sharing information are critical to reaping benefits from electronic health information, Yeager adds. “For example, there’s an alarming low percentage of technology used in care coordination,” she notes. “Workflow is just a big missing piece – the capabilities exist, but we just don’t have it baked into the system.”

Federal agencies have sought to nudge the industry toward information sharing, introducing it through meaningful use requirements, trying to encourage it through industry collaboratives, extensively investing nearly $700 million in health information exchange development in states and regions, and recently implementing provisions of the 21st Century Cures Act to prevent information blocking, which interrupts access to patient information – either by patients themselves or healthcare organizations.

QHINs have a lot to work though in terms of meeting standards set by Sequoia for cybersecurity, financial stability, and having the capacity to handle expected high volumes of records and data processing, Yeager says. “When we start relying on this, it becomes critical infrastructure and we would not want ‘brownouts,’ “ she adds. “We’re seeing a significant amount of due diligence (from the candidate QHINs), and we need to ensure good network governance. There’s a certain level of trust we need to ensure to make sure they are qualified networks.”

“Coming out of the pandemic, few would disagree that this is serious national infrastructure,” Tripathi adds. And he highlights the diversity of the applicant QHINs – which include networks, technology vendors and one of the nation’s largest electronic health records system vendors – as a way to inculcate creativeness and a wider range of services. “While nothing is live yet, we don’t want to get out ahead of this – we want to balance how we still preserve innovation and not just having organizations that are too big to do that. These should develop organically.”

Both Tripathi and Yeager believe some of the QHINs will go live this year, which was an expectation they had hoped to meet.

Still, some unknowns

However, many questions still surround how TEFCA will operate through the QHINs.

TEFCA will standardize how QHINs, and the organizations that connect to them, will coalesce around standards, privacy and security practices and agreements between partners.

Some will evolve over time. For example, exchange of data based on the Fast Healthcare Interoperability Resource (FHIR) standard is expected to begin next year. Many industry experts had hoped that FHIR-based exchange could have been rolled into TEFCA sooner.

For existing health information exchanges and intermediaries supporting information exchange, much remains unclear about TEFCA, says Lisa Bari, CEO of Civitas Networks for Health, an organization representing HIEs, regional health improvement collaboratives and health data utilities. “Because of the uncertain timeline and impact, it makes it hard for organizations or businesses to plan,” she adds. “Contracts in healthcare take a long time (to finalize). Governance and other agreements don’t happen overnight. Uncertainties around launch dates, scope, start times and more make it hard for prospective participants to proceed.”

How QHINs will mesh with existing health information exchange entities also remains a concern when it comes to the potential for duplicative services, and particularly how quickly multi-state QHINs will be able to understand and meet regulations for individual states and localities, she adds.

Tripathi acknowledges that there will be details to work out in the early stages of the initiative. “We recognize that there’s going to be a transition here, and it’s going to feel like there is redundancy and overlap. That’s something that we’ll have to work through so it’s deliberate and not confusing, and that it doesn’t represent a double cost for participating organizations.”

While it’s believed that about 70 percent of healthcare organizations currently have access to existing national information exchange services, many express concerns about how to connect the remaining organizations into a national network. Smaller providers, small physician practices, federally qualified health centers, public health agencies and non-acute care organizations that are not part of larger health systems may face shortfalls in technical expertise and financial capacity to connect. It’s not clear how that will be funded.

Some say that more value from national exchange will be realized when diverse partners, such as payers and public health agencies, can move other types of information, such as administrative transactions and public health data. Participation in easier exchange of data won’t just happen because the networks can do it – that’s a variation of the “build it and they will come” thinking that assumes everyone intuitively understands the potential, Bari suggests. The benefits will need to be marketed, and new participants will need a helping hand, she says.

“From the concept perspective, Civitas members are extremely supportive on nationwide exchange,” she notes. “All of our members are involved in nationwide exchange. We’re supportive of these goals for standardized exchange – all of these things I believe in. There are just some really important implementation details on the ground.”

Tripathi says all participants in TEFCA anticipate the additional work that lies ahead, and there’s growing appreciation that expansive and nationwide exchange can make everyone’s life easier.

He looks no further than a recent accident involving his mother that resulted in her breaking her hip. “We moved her to a rehab hospital that we knew was connected to an inpatient facility via Carequality,” he recalls. Frustratingly, medical records could not be forwarded electronically.

“Instead, they handed us a stack of paper (records) and told us, ‘They will scan it and upload it.’ Really? It just impressed on me all the more that we need to implement (TEFCA). We have to shut off those other ways of exchanging information.”

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