Benefits for Health Information Networks (HINs)

Together with the Office of the National Coordinator for Health Information Technology (ONC), we are building the Trusted Exchange Framework and Common Agreement (TEFCA) established by the 21st Century Cures Act. Once operational, the TEFCA will facilitate exchange of health information on a nationwide scale, simplify connectivity among networks, and create efficiency by establishing a standardized approach to exchange policies and technical frameworks. 

The TEFCA will offer a nationwide approach for the exchange of relevant health information to support a range of exchange purposes, such as treatment, payment, quality assessment, benefits determination, consumer access to health information, and public health. 

The TEFCA will provide a common set of rules that are federally recognized, greatly reducing the burden health information networks (HINs) currently face when they try to establish connections with entities outside their networks. Consistent policies and technical approaches will increase the overall exchange of health information. The TEFCA will also provide a structure for engaged parties to work together on coordinated, uniform adoption of new technologies and use cases over time.

The ultimate goal of the TEFCA is to enhance provider and consumer access to health information that supports better clinical decision-making, improved outcomes, and lower costs. HINs participating in the TEFCA will play a pivotal role in reaching that goal and will benefit greatly from its achievement. 

The Benefits of the Network Based on the Common Agreement for HINs

For participating HINs, the network based on the Common Agreement will expand their ability to enable or facilitate access to data nationwide and create efficiencies that will deliver greater value to their participants. The network based on the Common Agreement does not preclude, and may very well enhance, other business lines. For example: 

HINs will be able to more easily and efficiently enable or facilitate access to health information from participants outside their existing community—such as retrieving a patient’s electronic health information for care received while on vacation or after a move, or sharing data across state lines in a region. This access to a broader scope of data increases the value of participating in a HIN.

HINs will be able to connect with a broader scope of actors outside of their own networks. For example, the messaging function will allow HINs to support providers in sharing electronic health information with public health departments or schools beyond their own networks.

With fewer barriers to connection and greater access to information, a broader range of provider types and health care organizations—such as ambulatory providers, behavioral health professionals, long-term or post-acute care facilities, other care settings, and health plans—may be interested in sharing health information through the network based on the Common Agreement.

HINs will be able to minimize one-off connections, which will greatly reduce the burden and complexity of exchange.

Creating a more efficient flow of data will allow HINs to focus more on value-add services and innovative business lines such as expanding directory services. For example, HINs may want to expand their services beyond the “block and tackle” of infrastructure to include alerts (such as for hospital admissions), dashboards, data analytics, or other data services. Among the possibilities for expanded services are support to hospitals in meeting new federal obligations to alert providers when a patient is discharged; maps identifying communities with high rates of chronic disease and other resources to better understand population health; improved understanding of social determinants of health; services to support value-based care; or creation of artificial intelligence solutions.

The Basics of the TEFCA 

ONC has awarded a cooperative agreement to The Sequoia Project as the TEFCA Recognized Coordinating Entity (RCE) responsible for developing, updating, and maintaining the Common Agreement. The RCE will also play a central role in operational activities for the TEFCA, including ensuring ongoing performance and creating a participatory and trustworthy governance process.

The trust framework that is at the heart of the TEFCA will provide a single set of rules that address permitted  data uses, privacy and security policies that must be followed, breach notification requirements, consumers’ ability to access information, and other policies that must be in place before data can flow. The TEFCA policies will align with existing federal rules, such as HIPAA, and will not replace relevant existing laws at the state or local levels. 

The technical standards underlying this resilient and reliable network-of-networks approach will connect Qualified Health Information Networks (QHINs) and enable them to share electronic health information across the entire nation. QHINs will be the central connection points within the TEFCA, responsible for routing queries, responses, and messages among participating entities and individuals. Members of participating HINs will be able to request and receive electronic health information from QHINs in the TEFCA starting with query and message delivery. 

The TEFCA will be governed by a Common Agreement that is signed by the RCE and each QHIN. Some provisions of the Common Agreement will flow down to other entities, such as QHIN Participants. The QHIN Technical Framework (QTF) describes the technical and functional requirements for electronic health information exchange between QHINs and will be incorporated into the Common Agreement. The QTF addresses, among other things, common approaches to patient identification, authentication, and security. The QTF will include a standards-based approach to directory services—a challenging aspect of exchange. Exchange within a given QHIN will generally be covered by the QHIN’s participant agreements and technical requirements. Implementation timelines will take into account the need to modify existing agreements to be consistent with the TEFCA trust framework.

Considerations by Role

A key question HINs will need to consider is whether to become a QHIN or connect to a QHIN. The RCE will evaluate candidate QHINs against specific criteria drawn from the QTF and the Common Agreement. While the final requirements are under development, QHINs will be expected to have an existing network that provides the ability to locate and transmit electronic health information between multiple persons or entities in a live production environment. They will also need to demonstrate their ability to support exchange consistent with the QHIN technical approach on a nationwide scale and meet the requirements of the Common Agreement. 

In considering whether to become a QHIN, HINs might ask themselves the following questions:

  • Do you have an existing network in production that will support nationwide exchange? If not, what will it take to reach that level?
  • How do your current capabilities compare to the proposed exchange purposes and technical specifications that have been released to date? 
  • Will your technology partners be able to support the scope of exchange expected?
  • Do the high performance expectations of QHINs align with your mission, capabilities, and business model?
  • Would building the capacity to be a QHIN convey benefits in and of itself by improving your core infrastructure?
  • How can becoming a QHIN expand your scope of exchange services? 
  • Would becoming a QHIN support other business lines or create new opportunities?

If, after consideration of the above HINs wish to pursue QHIN status, they may begin to develop the capacity and characteristics needed to achieve such designation. This is, of course, with the understanding that the final criteria are still under development. All HINs are encouraged to engage with the RCE during this development process.

The Participant HINs will deliver the value of the TEFCA throughout the healthcare system by  connecting their own participating providers, health care organizations, public health agencies and consumers to this efficient and broad scope of nationwide exchange. While Participant HINs will need to meet certain flow-down requirements in order to participate in the TEFCA, they will not have the same intensive operational and compliance obligations as the QHINs but they will be able to realize the benefits.

Now is the time to evaluate how existing business models can be extended or expanded as the scope of data and ease of making connections is likely to grow exponentially. While the full set of policies and technical requirements for the TEFCA are still under development, there are steps HINs can take now to prepare. HINs should:

  • Review the terms and obligations in the draft TEFCA and compare them to your current participant agreements;
  • Take stock of your current technical capabilities and technology partners to determine whether they can be scaled to accommodate the greater scope of exchange that the TEFCA will bring;
  • Perform a business assessment to determine whether a broader scope and scale of exchange creates new opportunities to focus on providing value (e.g., alerts, analytics, other data services);
  • Evaluate your existing network to determine whether additional participants could benefit from connecting to the TEFCA through your services;
  • Perform a risk assessment to determine whether or not your organization should participate in the TEFCA; and
  • Assess your relationships with national networks that could become QHINs.

On the Radar

As we continue to develop the TEFCA, the RCE is committed to informing the community about key developments through informational calls and updates. Activities underway include:

  • Development of a participatory governance structure to ensure a transparent and fair process that includes representation of key stakeholders, including HINs, among others. 
  • Development of transparent and efficient application and onboarding processes for QHINs.
  • Development of the Common Agreement Draft Version 1 and QTF Draft Version 2, which will be delivered to ONC and subsequently available for public comment.

The RCE is committed to taking a practical approach to implementation that will seek to minimize burden and build on what is working today. This includes establishing timelines that are sensitive to the scope of any necessary changes that QHINs and Participants need to undertake. We encourage all HINs and other stakeholders to engage with us as the community works together to realize nationwide health information exchange.

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