What are TEFCA and QHINs — and how can they benefit you?
The 21st Century Cures Act (Cures Act) was signed into law on December 13, 2016, by the Obama Administration and is designed to help accelerate medical product development and bring new innovations and advances to patients who need them faster and more efficiently. The act advocates for the delivery for greater interoperability, promotes the adoption of electronic health records (EHRs) and supports human services programs.
The broad impact of the act was the expansion of rulemaking ability for two key regulatory agencies — The Office of the National Coordinator for Health Information Technology (ONC) and the Centers of Medicare and Medicaid Services (CMS).
Many initiatives were included in the subsequent rulemaking — most notably provisions around information blocking and patient access. These rules also contained specific technology provisions requiring the use of Fast Healthcare Interoperability Resources (FHIR), a shared standard to facilitate exchange. On a longer trajectory of rulemaking was the Trusted Exchange Framework and Common Agreement (TEFCA), largely due to the ambitious nature of the project.
In this blog, we explore TEFCA, Qualified Health Information Networks (QHINs) and the significant opportunity presented to post-acute providers to enter a level playing field with their partners in acute and ambulatory care settings.
What is TEFCA?
TEFCA is made up of two parts: the Trusted Exchange Framework and the Common Agreement. The Trusted Exchange Framework details standards that networks must follow when sharing data, while the Common Agreement is a legal agreement that governs data sharing between networks.
The combined components are a definition or implementation guide for how nationwide exchange between providers across the healthcare continuum will work. Contained therein, are rules for how technology vendors must comply to exchange information on a national scale. The definition of TEFCA, which will continue to evolve, is managed by the Recognized Coordinating Entity (RCE). These governing definitions and agreements are the criteria in which QHINs are certified to act as the exchange on behalf of providers.
This may all sound familiar, for those working with entities like Carequality and CommonWell, as they are intellectual predecessors of TEFCA and QHINs respectively. Carequality acted more as a framework for exchange with members implementing the method, and in accordance with that path, Carequality is part of the RCE group helping to define TEFCA. CommonWell, with its well scaled services and large membership, has become one of the new certified QHINs facilitating nationwide exchange with other certified vendors.
What are QHINs?
QHINs are certified under TEFCA, with their primary role being the technology solution to allow the objectives of TEFCA — nationwide healthcare exchange — to be realized. In December 2023, the ONC named the first QHINs and as of today several more have been named. The list is filled with well-known names in healthcare including Epic, CommonWell, Health Gorilla, MedAllies, SureScripts and several others.
Adopters of QHIN exchange must support at minimum HIPAA-covered transactions for treatment and patient access, meaning requests from other providers or patients for records must be fulfilled. Other covered transactions relating to payors are currently optional, but expansion in this area is expected in the coming months and years.
The initial phase of QHIN requirements is similar to previous networks in that they are heavily document based — well adopted tech standards like C-CDAs (discharge, transfer, and encounter summaries, etc.) as well as non-structured documents like PDFs or images. The minimum participation requirement is sharing a C-CDA. The Common Agreement 2.0, released in late April 2024, details further exchange standards using FHIR. We can safely expect the focus to be on FHIR-based exchange for the foreseeable future.
Aside from the technical consideration and approach, the certification of QHINs has created a new market of vendors selling solutions in this newly defined space. On the optimistic side, this approach could lead to innovative solutions competing to provide the most valuable services; on the pessimistic side, this could lead to a disjointed and inconsistent patchwork of solutions running amok. Whether you lean one way or the other, most will agree the TEFCA program will see a diverse group of solutions all with the same common goal of enabling better care.
QHINs are the pillars of TEFCA’s network-to-network exchange, providing shared services and governance to securely route queries, responses, and messages across networks for eligible participants — including patients, providers, hospitals, health systems, payors, and public health agencies.
While TEFCA defined the technical and legal requirements for nationwide EHI exchanges, QHINs are the certified entities responsible for facilitating the national exchange of health information and will act as connectivity brokers to ensure interoperability between the networks they represent.
What are the benefits of TEFCA?
For post-acute providers, there are two key areas of value — a technology approach that can equal their counterparts in health systems, and a connection to a wider network of healthcare entities to create more value in a value-based care world.
While TEFCA is a national-level framework, the QHINs cover regional participants including existing actors like Health Information Exchanges (HIEs), state-backed or private entities tied to a hospital system. In addition, with entire EHRs like Epic becoming QHINs (with more expected), the number of referral sources and other healthcare providers a post-acute organization can connect with and demonstrate value to will continue to expand. This creates an opportunity for post-acute providers to achieve local connectivity with ACOs and hospitals, regional and state connectivity to HIEs, as well as national scale — all with a single connection providing value at each level.
Within this expanding network, there are useful incentives that can create a level playing field for providers in all settings. Under rule HT-1, providers gain coverage for information blocking including patient access when both entities are participating in TEFCA. The same incentives have significant meaning for acute and ambulatory providers, who in some cases are dealing with thousands of information requests every day. All of this is on top of the exchange framework itself, the value of connecting providers and allowing the exchange of information to facilitate better care and outcomes.
How do I get started?
If you’re interested in realizing potential benefits from national-level exchange,
- the first thing to do is decide what you want to achieve as an organization. For example, “we aim to grow referrals from Memorial Hospital by 10%.”
- Next is to talk to your EHR partner. Understand what connectivity tools are available, is there QHIN support, or another older exchange method. Understanding what you have to work with is key to deciding your approach.
- Deploy technology as rapidly as you can to achieve connectivity — like a QHIN that won’t create a project for the hospital’s IT team — and make sure your referral partner knows about your effort.
- Leverage the new connections to differentiate from competitors and repeat with other referral partners.
The technology to allow organizations to move more efficiently, focus on care, and demonstrate value to partners and referral sources can all be found in the national-level connectivity defined by TEFCA. We encourage all post-acute organizations to build an interoperability strategy and include a QHIN in your approach.
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Chris Pugliese
Chris Pugliese, Director of Product Interoperability, ResMed SaaS. Chris has spent the last decade working with post-acute technology and EMRs, and the last 5 years focused on interoperability. His strength is enabling technology, as well as educating on the growing importance of interoperability and its benefits to the post-acute care settings. In a short time, Chris has become a leader, spearheading integration and interoperability initiatives within and outside of MatrixCare. Recent industry committee roles and responsibilities include: Leadership Team Member for the Post Acute Interoperability Work Group (PACIO), Technical Lead for the Functional Status Subgroup for the PACIO initiative – developing FHIR Profiles for Functional Status, CommonWell Health Alliance Use Case Committee member, CommonWell Health Alliance Specification Workgroup member
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