Unlocking Healthcare's Data with a National Network: TEFCA's Game-Changing Impact on Providers, Patients and Payers 

The journey of the Trusted Exchange Framework and Common Agreement (TEFCA) from conceptualization to becoming operational is an ongoing tale marked by perseverance, progress, and a transformative shift in healthcare data exchange. It’s been 20 years since the effort to launch what was initially known as the Nationwide Health Information Network began, and although there has been increasing adoption of state and regional health information exchanges (HIEs) and a quilt work of national network initiatives such as the eHealth Exchange, stakeholders still have not fully been nationally connected.

The turning point arrived in 2022, when momentum accelerated with publication of version 1 of TEFCA, along with the unveiling of the Qualified Health Information Network (QHIN) selection criteria and process. The Sequoia Project’s diligent efforts, such as the QHIN Recognized Coordinated Entity (RCE), included engaging the public through comment periods, which culminated in a significant milestone at the close of 2023.

The announcement and contract signing of the first selected QHINs at the end of the year, along with their operational launch, marked a pivotal moment on TEFCA’s path. The five inaugural QHINs – eHealth Exchange, Epic Nexus, Health Gorilla, KONZA National Network and MedAllies – are a very diverse set of organizations. Two other organizations, Kno2 and CommonWell Health Alliance, were just announced as official QHINs earlier this month. More organizations are moving through the application process or have expressed intent, including Surescripts, eClinicalWorks and Velatura Public Benefit Corp.’s United States QHIN. These organizations will act as supernodes along TEFCA’s “network of networks,” facilitating the national exchange of health data.

Interest in making national healthcare data exchange a reality has never been stronger, given that TEFCA facilitates network-to-network exchange, allowing participants such as patients, providers, hospitals, health systems, payers and public health agencies to securely share critical health information. As we unravel the layers of TEFCA's evolution, we delve into what this means for providers, patients and payers, uncovering the implications and possibilities for all that express interest in healthcare data exchange. While TEFCA is still voluntary, we expect regulatory authorities to offer an increasing number of incentives over time, spurring its evolution and resultant improvements in data exchange, care coordination and clinical outcomes.

Version 2 of TEFCA Defines the Path Forward

TEFCA’s journey continues with version 2. Published on January 19, 2024 with a 14-day comment period, v2 is expected to be finalized this quarter.

One of the key themes of v2 is explicit support for Fast Healthcare Interoperability Resources (FHIR), including stages 1 and 2 of the latest FHIR roadmap. While earlier versions of TEFCA could carry stage 1 FHIR payloads (e.g., just content), v2 introduces QHIN-facilitated FHIR (stage 2), in which the QHINs are used to discover FHIR endpoints. In stage 2, the actual FHIR-based exchange of data between organizations is still handled outside of TEFCA. The third and fourth stages of the FHIR roadmap are expected to play out in TEFCA over the next few years. In stage 3, QHINs use FHIR to exchange data among themselves. Stage 4 provides end-to-end FHIR exchange whereby QHINs fully handle FHIR exchange for their participants.

• Stage 1 – FHIR Content Support (e.g., payloads)
• Stage 2 – QHIN-Facilitated FHIR Exchange (end point discovery)
• Stage 3 – QHIN-to-QHIN FHIR Exchange (FHIR between QHINs)
• Stage 4 – End-to-End FHIR Exchange (participant to participant through TEFCA)
• The proposed v2 changes will also require more standardized language and provisions in the contracts between QHINs, participants and subparticipants to improve consistency and close potential gaps in nationwide data sharing. (In TEFCA’s current version, QHINs have significant flexibility in how they structure agreements with their participants and subparticipants.)

In essence, v2 will require more explicit TEFCA requirements to flow down to participants and subparticipants instead of QHINs continuing to define many of their own terms and conditions. This limits flexibility but increases harmonization across all entities in the interoperability framework.

Some additional changes in v2 include:

• Revised exchange objectives to include a tailored selection of “purposes,” namely payment and healthcare operations, to more closely mirror the Health Insurance Portability and Accountability Act (HIPAA)
• Integration of QHIN push messaging capability alongside discontinuing the exchange of data at the population level
• Expansion of QHIN criteria to allow a wider array of health information networks to be recognized as QHINs
• Separation of technical standards into their own specific framework, dubbed the QHIN Technical Framework, to foster independent development of technology

TEFCA: Industry Perceptions and Challenges on the Horizon

From concept to operational reality, TEFCA has been widely hailed as a positive stride toward interoperability, though dissenting voices have surfaced, particularly regarding the FHIR Roadmap for TEFCA. Concerns have been raised, with some industry stakeholders contending that TEFCA's emphasis on document-based approaches, rather than FHIR application programming interfaces (APIs) (more explicitly, Clinical Document Architecture and Integrating the Healthcare Enterprise), and the extended length of the FHIR onramp might stall industrywide FHIR adoption, potentially resulting in the unintended consequence of slowing progress toward interoperability.

Despite these reservations, a broader industry consensus acknowledges TEFCA's potential role in achieving interoperability goals. Insights from annual meetings over the past few years involving Sequoia, Carequality, CommonWell and the Office of the National Coordinator for Health Information Technology (ONC) have revealed ongoing challenges in understanding the readiness for transactions beyond provider-to-provider on the network. Notably, and not surprisingly, a divergence of opinions has emerged between vendor and provider stakeholders.

National Coordinator Micky Tripathi stands firm on ONC’s commitment to integrating FHIR into TEFCA. The FHIR roadmap expects QHIN-facilitated FHIR exchange to be adopted in 2024, QHIN-to-QHIN FHIR to take hold in 2026 and end-to-end FHIR exchange in the years to follow. This commitment extends to a vision in which payers and various stakeholders seamlessly integrate within the framework to maximize its value.

Other federal agencies, like the Centers for Medicare and Medicaid Services have also signaled their focus on TEFCA as a conduit for leveraging data and communicating across the network with all stakeholders by starting to name TEFCA in its rules. The eHealth Exchange has led the way here with its longtime support of connectivity for the Social Security Administration, the Veterans Administration, etc. Greater use of TEFCA for public health will also be a welcome advance.

Amidst this progress, clearinghouses continue to operate independently of TEFCA, posing another potential barrier to true national data exchange and prompting questions about potential shifts in their business landscape if TEFCA takes over some, many or perhaps all of the transactions from which they currently profit. (After all, why have separate networks for administrative and clinical information, especially as the lines blur in the areas of quality, population health and prior authorizations). TEFCA exchange purposes for healthcare operations and payment are just the beginning of what may take hold and expand. (An updated standard operating procedure has been released for healthcare operations but not yet for payment.)

Ultimately, TEFCA is emerging as a force that may contribute to leveling the playing field, offering organizations of all sizes and resource levels a single onramp to access and exchange patient data. This ongoing journey, marked by dissent, positivity and evolving dynamics, highlights TEFCA’s ability to shape the future of healthcare data exchange.

Harmony Between HIEs and QHINs: Navigating Contracts and Consent

As we delve deeper into the collaborative landscape of healthcare data exchange, the synergistic relationship between HIEs and QHINs comes to the forefront. Understanding their roles in tandem provides a nuanced perspective on how these entities contribute to the seamless flow of electronic health data.

Contractual Dynamics with HIEs: Tailoring Data Exchange

While TEFCA introduces a national technical and trust framework and network for data exchange, HIEs retain their significance through customized contractual agreements. Organizations can sign contracts with HIEs to define the scope of shared and exchanged information; for example, they can choose to receive data but not provide it. This flexibility allows a tailored approach, offering organizations a measure of control over the types of data they choose to share with the HIE.

When it comes to QHINs, participants, who can be HIEs, sign an agreement with a QHIN and agree to exchange all relevant data they have about a patient unless prohibited by HIPAA or other existing laws or exceptions. A key issue here is the boundary of the entity that signs the agreement. It may be only a part or division of a larger parent organization that signs the agreement, which could allow it to hold some information back. The same is true for the boundaries of a QHIN within a larger organization. Epic, for example, has created Epic Nexus as its QHIN. Providers that do not choose Epic as their QHIN would be handled differently than clients that do.

Consent in the Era of TEFCA: Navigating Privacy Standards

TEFCA's emphasis on standardized processes aligning with HIPAA regulations sets the stage for secure and compliant data exchange. HIEs, by contrast, operate within a more localized scope and handle consent dynamics differently. TEFCA leans on HIPAA for privacy standards while HIEs, through contractual agreements, provide organizations the ability to navigate and manage consent in a manner that aligns with their specific needs. More work is needed in the industry to standardize consent management to improve the patient’s ability to grant and revoke consent not just for their entire record but also discrete data elements.

HIE Offering Additional Services Leveraging TEFCA Data

The collaborative dance between HIEs and emerging QHINs will ensure secure, tailored and standardized data exchange that will enable many additional benefits, such as better analytics. Many HIEs already offer value-added services using the data in their existing networks, enabling members to access advanced data analysis. By connecting to TEFCA, HIEs can now apply the analysis tools they already offer to a broader data set. Some HIEs may set themselves apart by offering advanced data analysis themselves.

KONZA, one of the inaugural QHINs, is an HIE operating in multiple states and plans to connect with as many HIEs as possible. To learn more about this particular QHIN and its plans, listen to our Dish on Health IT podcast to hear from Laura McCrary, president and chief executive officer of KONZA. 

Unveiling the Next Chapter: TEFCA's Potential Impact on Payers, Providers and Patients

As TEFCA evolves into a dynamic network, stakeholders across the healthcare spectrum must navigate uncharted territory, exploring its implications for payers, providers and patients. As we delve into this unfolding landscape, Point-of-Care Partners (POCP) and industry experts offer insightful perspectives, acknowledging that these early predictions are educated guesses, subject to change, yet crucial for shaping expectations around TEFCA’s potential.

Payer/Provider Data Exchange: Navigating Unexplored Realms

Stakeholders are keen to understand how the TEFCA network will facilitate seamless data exchange between payers and providers. Exploring the positive and possibly negative implications for API implementation, specifically concerning interactions among payers, providers, and patients, is emerging as an area of critical focus. Policymakers face the challenge of addressing policy and privacy implications, necessitating a careful reevaluation of frameworks such as HIPAA.

TEFCA's Impact on Provider Workflow and Patient Engagement: Shaping New Realities

TEFCA’s influence on provider workflow and patient engagement is steering the industry toward transformative changes. The traditional approach of patients accessing their data through provider-specific portals - with the associated challenge of managing multiple logins, - is undergoing a paradigm shift. Now more than ever, patients are being empowered to access their data, emboldened by more defined rights set forth within ONC’s new information-blocking rules. This heightened sense of patient engagement is paving the way for a streamlined and centralized data access experience.

This evolution, however, necessitates a fundamental shift not only in how provider organizations offer data access to patients but also in how providers educate patients on accessing those data. Providers will likely need to take a proactive approach in keep patients informed and engaged as data access options evolve.

Initiatives for Patient Empowerment: The Role of Health Gorilla's Patient Access

Health Gorilla’s Patient Access service, which simplifies data access and grants control to patients, exemplifies the significant strides being made toward empowering patients. Health Gorilla’s patient-centric initiative aligns with the evolving ethos of TEFCA, which promotes individual access services as one of its six exchange purposes – all of which prioritize seamless data accessibility.

Overcoming Persistent Barriers: TEFCA's Role in Data Accessibility Journey

The persistent challenges of ensuring seamless data transfer throughout a patient's journey across care settings and locations remain at the forefront of healthcare concerns. Patient expectations for data to move seamlessly, even post-info-blocking, have been met with hurdles. TEFCA is emerging as a pivotal step in overcoming information blocking, aligning with the overarching goal of meeting and exceeding patient expectations. Participation in TEFCA will enable organizations to overcome these data-transfer challenges, enhancing clinical communication and care coordination efforts.

Payer Engagement and Pilot Initiatives: Focused on Efficiency

Several organizations are focused on bringing payers into TEFCA as members of QHINs. Several payers are already proactively engaging in pilot programs to showcase the value of their use cases. These endeavors focus on burden reduction and increased efficiency, emphasizing the benefits TEFCA can bring to the broader healthcare ecosystem. By addressing the challenges of seamless data transfer, these pilot programs, once adopted on a broader scale, can contribute to a more streamlined and patient-centric healthcare experience.

Testing and Pilots: Validating the Value Proposition

Anticipating a surge in testing and pilots, stakeholders aim to demonstrate the value of various use cases within TEFCA. The emphasis on proof through reduced hesitation and doubt plays a pivotal role in driving widespread acceptance and adoption across the healthcare ecosystem.

Evolving Business Models: Navigating the Economics of Data Exchange

The economic landscape of data exchange is also undergoing a transformation, with entities adopting diverse models. While QHINs cannot charge each other, questions surrounding QHIN pricing models echo the uncertainties seen with certain HIE business models. Will they, for example, charge more for payers to connect? Industry players such as Surescripts and Health Gorilla are strategically shaping their approaches to accommodate changing dynamics and target a broader spectrum of stakeholders. A recent informational webinar by Sequoia on Jan 30, 2024, clarified that participants cannot charge other participants for required responses via TEFCA. However, QHINs can, of course, charge their participants for connectivity.

FHIR Roadmap Evolution: Paving the Way for Comprehensive Data Exchange

The FHIR roadmap's evolution from a three-stage to a four-stage model reflects the industry’s commitment to advancing comprehensive data exchange capabilities. Challenges persist, as highlighted by real-world scenarios, emphasizing the need for enhanced data accessibility and comprehensive personal health records.

Navigating Uncertainty & Embracing Opportunities

In navigating this uncharted terrain, stakeholders must remain agile, adaptive and open to collaborative initiatives. As TEFCA continues to shape the future of healthcare data exchange, the journey unfolds with promises, challenges, and the collective aspiration for a seamlessly interconnected healthcare ecosystem.

As we embrace the promise and challenges of TEFCA, it's essential to acknowledge the uncertainties that lie ahead. Even with successful implementation, new questions will arise, and old problems may persist. Stakeholders must proactively engage in navigating these uncertainties to maximize TEFCA’s benefits. The following framework offers a good starting point.

How Should Your Organization Adapt to TEFCA?

1. Evaluate Your Needs: Assess your organization's requirements and understand the specific challenges TEFCA aims to address in your context.
2. Explore QHIN Options: Delve into the offerings of QHINs to determine which aligns best with your organization's goals.
3. Seek Guidance: Navigating the complexities of TEFCA can be challenging. Reach out to industry experts at POCP for personalized guidance and insights.
4. Stay Informed: Stay abreast of industry developments, pilot programs and evolving best practices to make informed TEFCA decisions.

Stakeholders have the opportunity to actively shape the future of healthcare data exchange. Together, let's navigate this evolving landscape, maximizing TEFCA’s potential for a seamlessly interconnected healthcare ecosystem. Reach out to us at kim.boyd@pocp.com and ken.kleinberg@pocp.com to discuss TEFCA-related strategies.