Episode Topic: TEFCA & The Intersection of Policy, Standards & Innovation


Pooja BabbrahPoint-of-Care Partners Payer & PBM Lead kicked off the episode by acknowledging guest, Dr. Steven Lane, Chief Medical Officer with Health Gorilla and Point-of-Care Partners co-host, Jocelyn Keegan , Payer/Practice Lead and HL7 Da Vinci Project Program Manager.  

Pooja then outlined the discussion for this episode. The hosts talked with Dr. Lane about:  

  • Trusted Exchange Framework and Common Agreement (TEFCA) 
  • Information blocking…or rather information sharing,  
  • Dr. Lane's transition from being part of a large health system to joining the health IT company, Health Gorilla and the different perspectives on innovation and change that come with operating in these quite different organizations.  
  • The cycle of innovation and the role of policy.  

Before jumping into the discussion both Jocelyn and Dr. Lane introduced themselves and explained that over the years they have worked with each other several times through the HL7 FHIR (Fast Healthcare Interoperability Resources) Accelerators with Dr. Lane participating in the Da Vinci Project and Jocelyn serving as the program manager of Da Vinci. Today’s hosts, Pooja, Jocelyn and the guest are all interoperability champions and share a passion for leveraging technology to improve healthcare.   

This episode’s guest, Dr. Steven Lane, Chief Medical Officer of Health Gorilla, member of the Health Information Technology Advisory Committee (HITAC) and longtime advocate for interoperability identifies as being a clinician first and that role brought him into the health IT space.  

Dr. Lane shared that he started using an EHR (Electronic Health Record) back in 1989. Worked on EHR implementation during the 1990’s and helped launch one of the first patient portals connected to an EHR back in 2001. He explained that he’s had more of an opportunity to engage in health IT throughout his career than most primary care physicians. He explained that the importance of interoperability started to be a real focus starting in 2008 and he had the opportunity to work with HIEs (Health Information Exchanges) and then was invited to take part in an ONC (Office of the National Coordinator) taskforce and just continued to say yes to any the opportunities that have come his way so he could contribute to progressing interoperability. He continued to say that in his view if we’re going to fix healthcare, we need to first focus on improving the health of our population. Second, improve the value of the healthcare being provided (reduced costs with optimal outcomes). Third, improve the overall experience of obtaining and delivering healthcare for the patients and for the providers, acknowledging that physician burnout is a real issue. Last, improving health equity.  

Pooja asked Dr. Lane to share a little more about the mission & vision of Health Gorilla to familiarize the audience.  

Dr. Lane explained that Health Gorilla started initially by addressing physician burden around lab orders and results. From there, they built a platform and started aggregating data they were exchanging and created a private HIE (Health Information Exchanges). They build a robust record service, master patient index, and then aggregate, normalize and de-dupe the records. The focus really being on data quality and utility. He compared the work to some of the regional HIEs, but Health Gorilla’s audience is much broader.  

Health Gorilla made early connections with CommonWell, eHealth Exchange, Carequality framework – Epic Care Everywhere, with Direct messaging through 3rd party health information service providers (HISPs) 

Dr. Lane shared that what he found special about Health Gorilla is the commitment to innovation and bringing in more data types like social determinants of health or data from wearables.  

Pooja then asked Dr. Lane to share his view of TEFCA and why Health Gorilla decided to apply to become QHIN (Qualified Health Information Networks)? 

Dr. Lane described the history of TEFCA, the initial idea for it being included in the 21st Century Cures legislation. He recalled that while interoperability had been a major focus of policy makers and the industry, providers and other stakeholders were still voicing frustration that they still couldn’t access the data they needed.   

The idea of TEFCA was for it to be an onramp to support all kinds of interoperability, data exchange and use cases. He expressed that he has had to learn patience as things in health IT never move as quickly as one might want.  

Dr. Lane went on to convey that early on after the announcement of TEFCA, Health Gorilla came out with a public commitment to apply to be a QHIN and be part of a diverse community of regional and national private and not-for-profit entities.  

He continued that becoming a QHIN for a private company is a big deal. They are inviting government oversight and commit to robust governance, state-of-the-art privacy, security and compliance practices.  

Health Gorilla is committed to supporting a broad range of cases and user communities like: 


  • Health Data Utility 
  • Public Health 
  • Community based social services 
  • Payer-provider
  • Individual Access Service


QHINs (Qualified Health Information Networks) will pursue multiple architectural approaches. Health Gorilla will be a data aggregator and platform. Health Gorilla will leverage TEFCA exchange as they do current HIN (health information networks) exchange to continue to build their secure cloud-based repository of health data with the goal to become the nation’s largest and most secure repository of high quality, high utility health data. 

Dr. Lane likened his vision of the role of a QHIN to that of a dance studio operator. He went on to explain that a dance studio operator creates a safe supportive space for people to come to dance. Different types of people - individuals or groups. Different types of dances – flamenco, ballet, private party. Everyone is invited to creatively use the space within specified constraints to ensure safety and privacy.  

Pooja followed up to clarify whether Dr. Lane likened becoming a QHIN as more opportunity for innovation.  

Dr. Lane said that absolutely it does. He explained that TEFCA is supplying a framework or single on-ramp and allows for more innovation in various use cases from treatment to payment and operations to public health.  

Pooja asked Dr. Lane to talk about TEFCA and FHIR. She explained that there has been some feedback in the industry voicing concern that even with the TEFCA FHIR roadmap there isn’t enough alignment between TEFCA and the FHIR community.  

Dr. Lane responded that many were disappointed that when TEFCA was originally announced there was no mention of FHIR at all but since then the TEFCA FHIR Roadmap was published. Some may not be satisfied with the current roadmap but it’s a good step in the right direction.  

Related to the TEFCA FHIR Implementation guide, Dr. Lane summarized some of the responses explaining that there were 16 commenters – Provider organizations, EHR and other HIT (Health Information Technology) vendors, public health departments, HL7, DirectTrust, HISPs, and others 

Some commenters called out the challenges of scale especially around registering and managing endpoints. Others pointed out the need to leverage and align with other work in the FHIR community. Others still pointed out the need to clarify the priority between developing to IHE (Integrating the Healthcare Enterprise) document vs. FHIR exchange for specific use cases. 

Dr. Lane went on to point out that there has been concerns about “if we build it will they come” but the number of QHIN applicants and the engagement seen with the comments submitted are a great sign that people are engaged with TEFCA. 

Pooja asked Jocelyn to chime in and share what she is hearing from the FHIR Accelerator community related to TEFCA and FHIR?  

Jocelyn agreed with Dr. Lane about seeing the level of engagement being a great sign. She added that there is starting to be a little bit of a cultural shift related to thinking about data outside of clinical data and how to use data to support billing, operations and more and how to use FHIR to do some of those things.  

Jocelyn explained that we’re starting to see a lot more traction. After attending the Carequality, Sequoia and eHealth Exchange meetings in DC in December and hearing the cacophony of voices talking about how to make TEFCA a reality and leverage FHIR was amazing.  

From a community perspective, Jocelyn explained that she is hearing a lot of positive feedback after seeing more real alignment happening with TEFCA and the FHIR community and there seems to be a feeling there is more of an openness akin to what happens in the standards development communities which was a needed next step.  

Jocelyn went on to say that in the near future the industry will need the volunteers to help pilot some of this work and prove we can move beyond point to point and settle the trust issue through these networks. What will be critical is technology meeting us where we are and solving real business challenges. Ultimately, while documents will continue to be part of certain transactions we really have to strive to get to codified data to get to the level of automation the industry needs.  

Dr. Lane seconded the notion of piloting now and not waiting until policy deadlines are looming. This is the time test, pilot and work out the bugs.  

Pooja remarked that it will be interesting to see how Sequoia as the Recognized Coordinating Entity (RCE) of TEFCA decides to engage more closely or not with the Accelerators, specifically FHIR at Scale Taskforce.  

Then Pooja asked Dr. Lane to discuss the huge transition from working for Sutter health, a huge health system to working with a health IT company. Pooja asked him to explain the different approaches to innovation he’s noticed.  

 Dr. Lane acknowledged that it is a big challenge to change the course of the huge ship that is healthcare. Things have evolved over the last 100 years or so resulting in the way healthcare is delivered today and it can be hard to change. Many providers may be resistant to change but then you have big disrupters like telehealth and other innovations that force that change.  

Dr. Lane explained that he has personally been deeply passionate about health IT and being innovative but for many years, he was the only provider in the room for years. That’s starting to shift but if the industry wants to see more engagement and willingness to change by providers, there needs to be the right incentives.  The most efficient way to innovate is to have all parties at the table with representation to make sure the work being done is solving the right problems.  

Dr. Lane expressed that he’s been at this for 20-30 years and he has recognized the improvement in the process for standards development, policy changes and innovation with people thinking about how we can do this in a coordinated and repeatable way to gain efficiencies.  

From a policy perspective, Dr. Lane explained, there will always be a need for carrots and sticks.  

Pooja then asked Jocelyn to share her perspective on the health systems that are members of Da Vinci and whether there are common attributes/factors that lead some systems to be more open to engaging with standards development and FHIR adoption? 

Jocelyn shared that before she jumps in she wants to point out that CMS (Centers for Medicare and Medicaid Services) has done a lot over the last decade to move the policy levers shifting the industry from a pay for service to a value-based care. This shift will require real-time interaction from a 60-90-day lag in information in provider systems. Health systems likely to be at the standards development table have recognized this shift to real-time exchange and own and master their own data.  

Jocelyn explained that one of the big attributes she’s seen in health systems who are more engaged in standards development are those that area a little further along in the value-based care journey and have strong partner relationships. A second attribute is having a willingness to go first and help prod their partners to move a little faster.  

Jocelyn went on to say that it isn’t just the big health systems that can engage, APIs will help level the playing field and enable smaller systems to operate more efficiently. She went on to say that sometimes all it takes is an individual with a passion like Dr. Lane to volunteer, come to the table and be willing to speak up and share the challenges they are facing during use case development. Standards development isn’t just for big health systems to participate and represent providers, it isn’t just for developers and implementers. For valuable work to be done the standards development process needs to understand the real-world problems that need to be solved. There is space for providers, pharmacists, grad students, really anyone in the ecosystem.  

Pooja made the point that this discussion is really about innovation, there is a role for and intersection of policy and standards development and the importance of stakeholder engagement and participation in these areas. She asked Dr. Lane to share his view of the policy role in innovation.  

Dr. Lane responded by saying that Jocelyn had it right when she talked about the importance of having different perspectives represented, especially when creating the initial use cases.  

Dr. Lane went on to say that in his role on HITAC and working on USCDI (United States Core Data for Interoperability). After the first version, other stakeholders were invited to the table to contribute and provide feedback and now there is a repeatable process that is done to update USCDI annually. He added that HL7 has been invited in as well and there is coordination there to ensure implementation guides reflect the latest coming version of USCDI.  

Pooja responded by saying that policy is really important in moving the industry forward but there is also a solid connection between standards development and policy and that in her role as chair of the NCPDP board, she may be biased, but feels organizations who don’t participate in standards development are really missing a big opportunity. HL7 and NCPDP see the value of coordinating and working together and CMS and ONC have made it clear through their roadmaps that standards will be named in coming policy so why not come to the table and make sure your organizational interests are being represented while also working to solve the big, complex issues in healthcare?   

Pooja then shifted the conversation mentioning that as we close out, we like to ask our guests if they have any final message or calls to action, they want to send to the industry? 

Dr. Lane responded by saying that he sees TEFCA as a once in a decade opportunity to really take nationwide interoperability to the next level. Right now, the general public probably has no idea what TEFCA is and that there should probably be more of a nationwide, public discourse and awareness so people can move towards it versus being dragged along.  

Pooja then asked Jocelyn for any concluding thoughts or calls to action she would like to send out.  

Jocelyn expressed her agreement with Steven, what are you doing to advance us as an industry, we’re all consumers of this data and ecosystem.  

She added that we are at an unprecedented time when the industry is leading and CMS and ONC are playing a critical role in alignment. The standards version advancement process (SVAP) is a notable example of CMS and ONC listening to the industry. They are no longer putting a ceiling on the level of advancement and progress the industry can make but rather focusing on establishing a floor.  

Jocelyn reiterated her encouragement of organizations and individuals to come and participate in the standards development process and give voice to your challenges so the industry can solve real problems.  

Pooja thanked cohost and interop expert Jocelyn Keegan and the well-informed guest, Dr. Steven Lane from Health Gorilla And thanks to our audience for tuning in!  

A friendly remind to new listeners that you can find us on Apple Podcast, Spotify or whatever platform you use to pick up your podcasts, including HealthcareNOW Radio and the Podcast Channel. We also post videos of our podcast episodes, sometimes longer versions, on the POCP YouTube channel. And don’t forget, Health IT is a dish best served Hot! 

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