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Frequently Asked Questions

The overall goal for the Trusted Exchange Framework and Common AgreementTM (TEFCA TM) is to establish a universal floor for health care information technology (health IT) interoperability across the country. The Common Agreement is the agreement signed by all Qualified Health Information NetworksTM (QHINsTM) that flows down to their Participants and Subparticipants through a static Terms of Participation. TEFCA’s infrastructure model and governing approach enables users in different networks to securely share information with each other—all under commonly agreed-to expectations and rules regardless of which network they happen to be in.

These Frequently Asked Questions address common questions and will be updated regularly. You may submit a question using our online form, attending our live monthly informational call, or emailing rce@sequoiaproject.org.

The Common Agreement and related resources are posted to the RCE™ website.

All capitalized terms below are specifically defined in the Common Agreement or another policy or technical document. Definitions can be found in the TEFCA Glossary.

Section 1:

What is TEFCA?

The TEFCA framework supports nationwide exchange of health information, consistent with Applicable Law. Participation in TEFCA:

  • Enables providers to get the data they need to provide the best care possible for patients.
  • Provides individuals with easier access to their complete health history.
  • Reduces burden for health plans and providers when sharing information to support care coordination, case management, and health care operations.
  • Provides public health departments with more seamless access to the information they need and simplifies connectivity for providers that currently expend tremendous resources connecting to numerous single-purpose public health reporting channels or report through non-digital means.

Under a contract with the Assistant Secretary for Technology Policy / Office of the National Coordinator for Health Information Technology (ASTP), the RCE:

  • Works with ASTP to update, implement, and maintain the Common Agreement, the Qualified Health Information Network™ (QHIN™) Technical Framework, and related policy documents;
  • Engages with communities to obtain feedback;
  • Designates QHINs and monitors QHINs for compliance with the Common Agreement;
  • Implements the governing approach and change management process in the Common Agreement; and
  • Develops and maintains the RCE Directory Service, which allows QHINs to identify other QHINs, as well as Participants and Subparticipants, to send messages to and to query for data.

Yes. TEFCA went live in December 2023. This means that:

  • The RCE has designated a number of Qualified Health Information Networks (QHINs) that are currently supporting health information exchange across their networks.
  • The QHINs have completed all of the steps, including technical testing, that are needed to be designated by the RCE™ and to engage in TEFCA exchange under a single set of rules established in the Common Agreement. The Common Agreement, along with the Terms of Participation that flow down to all Participants and Subparticipants, createtrust by ensuring that every entity connecting for TEFCA exchange has agreed to the same terms on topics including:
    • Purposes for which information can be shared;
    • Expectations for response to queries;
    • How information will be kept private and secure; and
    • Processes for oversight of TEFCA exchange.
  • The RCE hosts a directory that allows QHINs to identify other QHINs, as well as Participants and Subparticipants, to send messages to and to query for data.
  • The RCE will designate additional QHINs on an ongoing basis as they complete the application and onboarding steps.
Section 2:

How Does TEFCA Work?

The Common Agreement is an agreement signed by the RCE and each QHIN that establishes the terms and conditions, including the governing approach for users in different Qualified Health Information Networks (QHINs), to securely share information with each other. Common Agreement Version 2 was published in the Federal Register on May 1, 2024. Many elements of Common Agreement Version 2 are incorporated into the Terms of Participation, which must be signed by all TEFCA Participants and Subparticipants without modification.

Framework Agreement is an umbrella term that refers to both the Common Agreement signed by each of the QHINs and the Terms of Participation that all Participants and Subparticipants agree to without modification. The Framework Agreements bind all entities engaged in TEFCA Exchange to the same set of rules.

The QTF describes the technical specifications and functional requirements necessary for electronic health information exchange between QHINs. Like the Common Agreement, some requirements flow down to the Participants and Subparticipants. The QTF is referenced in the Common Agreement.

SOPs provide additional details to support the Common Agreement and QTF and describe how certain policy requirements should be operationalized by QHINs, Participants, and Subparticipants. For example, the Exchange Purposes SOP defines the authorized purposes (such as Treatment and Individual Access Services) for which data can be exchanged, including requirements for and exceptions to responding to a TEFCA Exchange query.

The RCE maintains a secure server where QHINs publish electronic endpoints and other necessary information about all entities that participate in TEFCA exchange. All QHINs have access to this information to enable their Participants and Subparticipants to locate where information can be shared or requested via TEFCA exchange. The information in the RCE Directory is considered confidential information and is not shared publicly. See the RCE Directory Service Requirements SOP for additional details.

Common Agreement Version 2 defines a Node as a technical system controlled directly or indirectly by a QHIN, Participant, or Subparticipant as listed in the RCE Directory Service.

Exchange Purposes are the reasons for which data can be exchanged using the TEFCA framework. TEFCA Exchange is authorized for the following Exchange Purposes under the Common Agreement: Treatment, Individual Access Services, Payment, Health Care Operations, Public Health, and Government Benefits Determination.

QHINs must support all of the Exchange Purposes, meaning that they must have the technical capability to enable themselves and their Participants/Subparticipants to receive and respond to queries for all of the authorized Exchange Purposes even if the QHIN and its Participants/Subparticipants do not initiate or respond to transactions for all of the Exchange Purposes in production.

QHINs, Participants, and Subparticipants must respond to any requests transmitted for Exchange Purposes that are identified as having a “required” response in the Exchange Purposes SOP (currently responses are required for Treatment and Individual Access Services).

The Common Agreement and QTF include strong privacy and security protections that build on existing requirements, such as those in the HIPAA Privacy and Security Rules. TEFCA privacy and security requirements generally apply to all entities participating in TEFCA exchange, whether or not they are Covered Entities or Business Associates under HIPAA.

The first production version of the QTF defined standards for exchange between QHINs, including specific transactions for document-based query and message delivery. While most organizations will initially exchange C-CDA 2.1 template documents, other formats such as PDFs and even FHIR resources are supported.

In accordance with the TEFCA FHIR Roadmap, QTF Version 2 takes steps to more fully deploy the FHIR standard in a network-to-network environment through QHIN-facilitated FHIR exchange. The RCE has created a FHIR Implementation Advisory Group to learn from activities (such as the FAST Initiative) and track progress towards deploying FHIR at scale. This will inform future steps to expand the use of FHIR on a network scale.

The FHIR Roadmap Version 2.0 includes four stages of FHIR® availability in TEFCA exchange:

  1. Stage 1: FHIR Content Support: QHIN-brokered exchange of FHIR payloads between QHINs is available (Common Agreement Version 1.1, 2023 and QHIN Technical Framework Version 1.1, 2023).
  2. Stage 2: QHIN-Facilitated FHIR Exchange: QHIN support for facilitated FHIR API exchange is required. Participant and Subparticipant exchange via FHIR APIs is available (anticipated in Common Agreement Version 2.0, 2024 and the QTF Version 2.0, 2024). 
  3. Stage 3: QHIN-to-QHIN FHIR Exchange: Support for exchange between QHINs via FHIR APIs is required.
  4. Stage 4: End-to-End FHIR Exchange: Support for QHIN-brokered FHIR Exchange between Participants and Subparticipants is required.

The QHIN Technical Framework (QTF) states that all data created or captured and sent on or after December 31, 2024 should conform to the appropriate data classes, data elements, and vocabulary requirements from the United States Core Data for Interoperability (USCDI) v1, when such data are maintained. Beginning January 1, 2026, all data created or captured and sent must conform to USCDI v3 data classes, data elements, and vocabulary requirements.

The RCE will determine requirements for referencing newer versions of the USCDI as they are released and adopted by ONC through regulation. For FHIR-based exchange in TEFCA, the FHIR Implementation SOP allows for the use of the HL7 FHIR US Core Implementation Guide v3.1.1 or higher, in accordance with ONC regulation. It is important to note that TEFCA exchange is not limited to the USCDI and may go beyond the data classes and data elements listed in any particular version of the USCDI.

The QHIN Technical Framework (QTF) requires the use of specific data fields and standards that will be included in TEFCA transactions  to identify Querying, Responding, and Message Sources. This will allow entities participating in TEFCA exchange to determine where queries and responses originate and incorporate this information into their own systems, as appropriate. Information shared via TEFCA exchange, such as C-CDA 2.1 format documents, may include additional information about provenance. The QTF also includes audit requirements for QHINs.

 

Section 3:

How Do I Participate in TEFCA Exchange?

Participation in TEFCA exchange is limited to the types of entities that are eligible to exchange information for one of the Exchange Purposes, using the definitions in the Common Agreement and Exchange Purposes SOP. Section 9 of the Common Agreement addresses Exchange Purposes, which include: Treatment, Payment, Health Care Operations, Public Health, Government Benefits Determination, and Individual Access Services.

To participate in TEFCA exchange, entities other than QHINs must:

  • Be connected into TEFCA exchange through a QHIN. This can be through a direct connection to a QHIN or through a health information network or technology provider that is already connected to a QHIN (collectively, a TEFCA connector);
  • Sign a Framework Agreement that binds all parties to the agreement to required flow-down provisions from the Common Agreement; and
  • Be listed in the RCE Directory Services by their QHIN.

TEFCA makes it easier for individuals to request and obtain their health information on their smartphones or via their patient portals. TEFCA exchange provides the infrastructure to more readily enable individuals to access their information, from every connected entity (such as providers, and health plans) in one place. Consumers will not sign a Framework Agreement but must have an agreement with a health app or other Individual Access Services provider in order to request their data via TEFCA exchange.

Yes. Common Agreement Version 2 and the Delegation of Authority SOP allow certain types of entities participating in TEFCA exchange, called “Principals,” to identify a “Delegate” that it has authorized to conduct queries on its behalf. All Principals and Delegates must sign a Framework Agreement and be listed in the RCE Directory. The authority provided to a Delegate must be documented in a written agreement and Principals must identify their Delegates in the RCE Directory. When conducting TEFCA exchange, a Delegate must identify the Principal for which it is initiating the transaction.

The Common Agreement prohibits QHIN-to-QHIN fees but does not specify how much QHINs and other TEFCA connectors can charge for their connectivity services. Whether fees are allowed between an initiator and a responder for a given Exchange Purpose is specified in the Exchange Purposes SOP. Responders may not charge fees for Treatment and Individual Access Services.

Section 4:

How is TEFCA Governed?

Common Agreement Version 2, the Governance Approach SOP, the Transitional Council SOP, the TEFCA Governing Council SOP, and the Advisory Groups SOP describe the governance mechanisms for TEFCA exchange.

A Transitional Council was established in February 2024 and will operate for twelve months. During that time, a permanent Governing Council will be established. The QHIN Caucus, Participant/Subparticipant Caucus, and, as appropriate, Advisory Groups will support the Governing Council’s work on specific topics.

Both the Transitional and Governing Councils will, among other duties:

  • Serve as a resource to the RCE and as a forum for orderly and civil discussion of any issues affecting TEFCA exchange;
  • Support the RCE in its work to monitor TEFCA exchange on behalf of ONC;
  • Provide advice to the RCE regarding issues before they become disputes and are escalated to the formal Dispute Resolution Process; and
  • Review proposed amendments to the Common Agreement, QHIN Technical Framework and SOPs and provide feedback to the RCE on proposed changes.

The Common Agreement, QTF, and SOPs will be updated over time to accommodate new technologies, requirements, or other changes necessary to support nationwide TEFCA exchange.

  • The Common Agreement Version 1 and QTF Version 1 were released on the RCE website in January 2023.
  • Common Agreement Version 1.1 was published on the Federal Register on November 7, 2023. The list of changes from Version 1 to Version 1.1 is available here.
  • QTF Version 1.1 was released in late 2023.
  • Common Agreement Version 2 was published in the Federal Register on May 1, 2024.
  • The QTF Version 2 was released in July 2024.
  • The RCE holds monthly public informational calls and is developing additional processes for receiving ongoing feedback from the public.

The Common Agreement and SOPs set forth a change management process for all subsequent updates to the Common Agreement, QTF, and SOPs that leverages a formal governance structure managed by the RCE.

All entities participating in TEFCA exchange must sign a Framework Agreement and are required to comply with those terms. QHINs are responsible for ensuring that all Participants and Subparticipants are abiding by the obligations that apply to them in the Terms of Participation and SOPs.

Each TEFCA transaction must provide information about a request for data. For example, every TEFCA transaction must include a specific Exchange Purpose code that identifies the reason for the transaction. Framework Agreements and relevant SOPs clearly outline what types of entities may use a given Exchange Purpose code. In addition, a Delegate must identify the Principal that has authority to request data in the transaction.

The RCE Directory will also provide information about TEFCA-connected entities. For example, QHINs must list all of the Exchange Purposes that will be initiated for and responded to by all Participants and Subparticipants in their network. Each directory entry must also list the Exchange Purposes that will be initiated from that specific system.

The RCE has specific oversight responsibilities over QHINs and TEFCA exchange more broadly. The RCE will rely on the bodies that make up the governance process for guidance and support. ONC has oversight responsibilities over the RCE through its contract with the RCE.

QHINs have specific and central responsibilities in overseeing their own networks. For example, the RCE requires that QHINs have documented onboarding policies for their Participants and Subparticipants. It is a QHIN’s responsibility to ensure that any Participants and Subparticipants it adds to the RCE Directory are compliant with all applicable obligations under the Terms of Participation.

If a dispute arises, the RCE will follow the process outlined in the Dispute Resolution SOP. The RCE is also developing a process to address issues raised by a QHIN, Participant, or Subparticipant prior  to the Dispute Resolution Process.

Section 5:

How are QHINs designated?

QHINs are expected to have the exchange infrastructure to act as the backbone of nationwide TEFCA exchange. QHINs are highly reliable, secure central nodes that support a network-of-networks approach to health information exchange. Entities undergo a rigorous review by the RCE™ before being designated. Some examples of requirements to become a QHIN include:

  • Creation of a Designated Network Governance Body;
  • Demonstration of compliance with the technical requirements in the QTF, including 12 months of prior experience supporting query functionality, as outlined in the QTF;
  • Demonstration of the requisite financial and personnel resources to support QHIN obligations; and
  • Evidence of formalized privacy and security controls, including certification under a nationally recognized security framework.

For more information on the requirements visit TEFCA and RCE Resources.

The RCE evaluates applicant QHINs via a rigorous process consistent with the Common Agreement and accompanying QHIN Application and QHIN Onboarding and Designation SOP. The designation process has multiple phases that include extensive review of the policy, security, technical, and organizational factors necessary to meet the requirements to be designated as a QHIN. Applicants also undergo extensive testing in both pre-production and production settings before final designation.

The QHIN Technical Framework (QTF) establishes technical and functional requirements for electronic exchange of information among QHINs. Certain elements are so fundamental that they are specified within the QTF and may require a QHIN to alter its approach for sharing information within its network. For example, the QTF requires that all communications use transport layer security (TLS) with mutual authentication. Beyond these types of elements identified in the QTF, each QHIN is free to choose how it shares information with its Participants.

Meet the QHINS

The Designated QHINs have been announced!

RCE is proud to introduce the designated Qualified Health Information Networks. 

Designated QHINs
eHealth Exchange logo
eClinicalWorks
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