On Jan. 18, the long-awaited Trusted Exchange Framework and Common Agreement (TEFCA), mandated by the 21st Century Cures Act in 2016, was released by the Office of the National Coordinator (ONC) and its Recognized Coordinating Entity (RCE), the Sequoia Project. The Trusted Exchange Framework (the “TEF” part of TEFCA) is a set of non-binding principles for health care data exchange, while The Common Agreement (the “CA”part) sets forth a technical infrastructure and governing approach to support data exchange.
The ONC states three goals as they introduce TEFCA:
1. Establish a universal policy and technical floor for nationwide interoperability
2. Simplify connectivity for organizations to securely exchange information to improve patient care, enhance the welfare of populations and generate health care value
3. Enable individuals to gather their health care information
To accomplish these goals, TEFCA puts special focus on sharing between information networks. In the TEFCA vision, certain information networks will be designated as Qualified Health Information Networks (QHINs). QHINs will act as high volume, high reliability hubs in the national network. QHINs will serve as brokers and facilitators for its participants and sub-participants, which may be health information exchanges, provider organizations, pharmacy systems, consumer applications, payers, etc. TEFCA explains the policies and technical requirements under which the QHINs must operate and specifies “flow-down” requirements governing QHINs’ interactions with participants and sub-participants.
A Health Information Network (HIN) may apply to the RCE to be designated a TEFCA QHIN. To be designated, it must meet the criteria specified in the Common Agreement – which deliberately set a “high bar” according to Sequoia’s CEO Mariann Yeager. The Qualified Health Information Network Technical Framework (QTF), which further specifies functional and technical requirements expected of a QHIN, was released along with the TEF and the Common Agreement. Also released are a set of standard operating procedures (SOPs) and, importantly, a Fast Healthcare Interoperability Resources (FHIR) road map, outlining the TEFCA plans for incorporating HL7’s FHIR in its interoperability plans.
If all this comes to fruition, you could envision a scenario in which a provider, when confronted with a new patient, is able to find and retrieve any and all care documents for the patient – ones in a competitor’s system across town or ones in a system across the country. Or an ER physician will be able to find a patient’s primary care provider and send the provider an ER discharge report, regardless of where the provider is located. These scenarios are treatment scenarios, but other exchange purposes – payment, health care operations, public health, government benefits determination, and individual access services (e.g., services used by consumer-facing applications that assist individuals in obtaining access to their health information) – are also authorized under the Common Agreement. More may be added over time.
Sounds fantastic! The effort and thoughtfulness that have been put into TEFCA are impressive and laudable. Of course, many questions remain. For instance:
1. Participation is, at this point, optional. The motivations an organization might have to apply to become a QHIN and that a provider might have to join a QHIN (or, more exactly, to join a participant or sub-participant associated with a QHIN) are still fuzzy, and it is yet to be determined if those motivations will be sufficient to create a sustainable national network. A QHIN may charge participants and sub-participants to offset its costs of running a QHIN, but it cannot charge other QHINs for sharing, and it must pay fees to the RCE for participating as a QHIN. Established HINs may find reputational benefits in becoming a QHIN, or they may find enough value in the expectation that QHINs will have a prominent voice in TEFCA decision making moving forward. But it’s a possibility that they may try for a time and find it financially unsustainable. Federal incentives or subsidies may be required.
2. Payers and health plans – both governmental and commercial – may start seeing so much value in TEFCA participation that they give incentives to providers that participate (or penalize providers who don’t). And that, of course, will motivate providers to participate. But at this point, it’s all conjecture.
3. And what if a provider or provider organization has been participating in an information exchange, the information exchange becomes associated with a QHIN, and the provider for some reason doesn’t want to associate with the QHIN? The opt in/opt out processes may become complex.
4. A very large key to the success of TEFCA – or any large scale sharing – is reliable patient identification and matching, which has been vexing the industry for years, and which the ONC and the RCE admittedly and understandably do not solve. In the scenario where a provider wants to find documents about a new patient, if the QHINs can’t correctly match on the patient identifiers and demographics the provider provides, the sharing grinds to a halt. Hopefully, effort such as the Patient ID Now project can progress us toward a workable solution.
5. Also unsolved is the problem of integrating sharing into provider workflows. It’s certainly a significant step forward to allow a provider to find all documents related to a patient. But it’s still a suboptimal provider experience if the provider has to move to a separate application/electronic health record (her) module to query, or view the retrieved documents, or keep checking to see if documents were found, or view any retrieved data in a format that’s different from the other data he or she normally reviews (e.g., having to review a Clinical Document Architecture (CDA) document instead of data in the normal structured areas of his or her electronic health record (EHR)).
6. Additionally, there’s the difficulty of achieving complete interoperability caused by incomplete and insufficient specificity in standards. FHIR profiling and iterations on the United States Core Data for Interoperability (USCDI) and organizations such as Graphite Health are working on that, but much work remains.
These are just some of the thorny problems that I wouldn’t expect TEFCA to immediately make go away. I’m highlighting that TEFCA is a commendable next step, but we still have a lot of work to do. But as General Patton once said, “A good plan violently executed right now is far better than a perfect plan executed next week.”
Some may and do argue that this isn’t a “good plan,” or that it’s taken years too long to get here, but I’m willing to defer such judgments and I’m excited to see what happens next. In the coming months, Sequoia will be hosting informational webinars to tell us more. I’ll be watching with interest.
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