Policy Primer: The Trusted Exchange Framework and Common Agreement (TEFCA)

Interoperability, or the exchange of electronic healthcare data, has had a number of roadblocks. Interoperability efforts were underway in earnest following the American Reinvestment and Recovery Act of 2009 (known as “the Recovery Act”), which included the landmark Health Information Technology for Economic and Clinical Health (HITECH) Act. This legislation ushered in an era of financial incentives to offset the costs associated with Electronic Health Record (EHR) adoption and the “meaningful use” thereof. Furthermore, the Department of Health and Human Services’ Office of the National Coordinator for Health IT (ONC), along with a public committee, was responsible for setting the technology standards that must be met for certified EHR technology.

 

While these efforts established the foundation for health information exchange to occur, total interoperability of clinical EHR data has yet to be realized. There are three big challenges that have been unresolved by the market to date:

 

1. Some areas lack clinical health data exchange altogether. This often relates to challenges covering some rural areas.
2. Other service areas are covered by multiple clinical health data exchange entities and participation in multiple arrangements is required in order to get patient information for their patient cohorts. This is generally due to competition between clinical data exchange entities.
3. Inconsistency between technology practices, security methods, data use agreements, lack of trust, and other unintended tensions between clinical data exchange entities, large provider systems, payers, and other stakeholders.  

 

In the meantime, there have been a number of legislative efforts to nudge end-users and participants towards selecting EHR vendors that promote interoperability. For example, the HITECH efforts for “meaningful use,” the certification standards for EHRs, and the ONC cooperative agreements with states were largely expected to be sufficient preconditions for comprehensive clinical health information exchange. The ONC and CMS also created a number of programs and policies to start and fund HIEs. However, the challenges listed above persisted.

 

With the passage of the 21st Century Cures Act (known as “the Cures Act”) Congress directed the ONC to create the Trusted Exchange Framework and Common Agreement (TEFCA), but it’s an optional framework for healthcare stakeholders. One assumption for this model is that if the current conditions are corrected, the market will move to this framework and a single on-ramp to nationwide interoperability and health information may be achieved.

 

The TEFCA includes the current players in the market, plus two new roles. There will be Qualified Health Information Networks (QHINs), which will meet security, technology, and organizational certification standards in order to demonstrate that they can and will impartially and meaningfully exchange data on a national basis. This will all be overseen, in cooperation with ONC, by the Recognized Coordinating Entity (RCE), which will have governance and qualification responsibility to ensure the QHINs are operating as they are required.

 

After being selected by ONC, the RCE will operationalize and execute the components of the TEFCA. In order for the RCE to be successful, QHINs will need to build infrastructure to connect to each other and exchange data, as well as the infrastructure between each QHIN and other end users and participants.

 

The nature of the TEFCA eliminates the need for end-users and participants to join more than one clinical data exchange arrangement. In other words, when end-users and participants submit data to a QHIN, then they will have complete data exchange potential.