Benefits for State Governments and Public Health

Together with the Office of the National Coordinator for Health Information Technology (ONC), we are developing the Trusted Exchange Framework and Common Agreement (TEFCA) as required by the 21st Century Cures Act. Once operational, the network based on the Common Agreement 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 network based on the Common Agreement will offer a nationwide approach for the exchange of health information to support arange of exchange purposes, enabling a multitude of use cases.

The Common Agreement’s rules will reduce the burden health information networks (HINs) and their participants currently face when they establish connections with entities outside their networks. Consistent policies and technical approaches will also increase theoverall exchange of health information. For example, in the area of public health, use cases could include electronic case reporting, immunization registry data sharing, or case investigation.

The Benefits of the Network Based on the Common Agreement for State for State Governments and Public Health

The nationwide network based on the Common Agreement will support participating state government and public health agency efforts to promote population health. The overall goal for TEFCA is to establish a floor of universal interoperability across the country. By providing a common baseline of legal and technical requirements for data sharing, the network based on the Common Agreement could help state governments and state and local public health agencies:

Improve access to population health data.

By offering more efficient data collection, the network based on the Common Agreement could power analytic tools, such as state-level public health dashboards to support population health management. These could include factors such as prevalence of chronic disease, identification of “hot spots”, or immunization rates by geography.


Further advancing interoperable exchange for Medicaid.

Medicaid providers could have more complete information for clinical decision-making, care coordination, and participation in value-based care arrangements. Medicaid programs and managed care organizations that choose to leverage the network based on the Common Agreement could have easier access to needed data for case management, quality measurement and reporting activities, risk adjustment, and closing care gaps, such as identifying enrollees that are missing immunizations or recommended diagnostic screenings. This could also support reduced costs to the state for interfaces they have with health care providers.


Support public health reporting. Simplifying information exchange will decrease the need for one-off connections to public health reporting systems and decrease the burden of on-boarding providers. This will facilitate a number of use cases, such as electronic case reporting, immunization reporting, syndromic surveillance, or lab and registry reporting. Streamlining the pathways to public health will increase the number of entities using electronic means, rather than paper, fax or phone, creating efficiency and allowing for greater use of reported data to support analytics and design of interventions.


Facilitate bidirectional exchange with public health. The network based on the Common Agreement will allow public health agencies to send messages to providers and conduct queries to support their public health functions, including identifying incidents and informing care providers of public health concerns. In addition, those seeking certain information from public health (e.g., treatment information from public health entities acting as a provider), may be able to query for the information they need. By leveraging the network based on the Common Agreement, public health can become more closely connected with health care providers, resulting in benefits for both.


Facilitate emergency preparedness and response. The network based on the Common Agreement would be helpful in providing access to health information for individuals receiving care in emergency settings and away from their usual sources of care. The infrastructure could also be used to gather and share information on response capabilities. This will support the tracking of response efforts in real-time.


Augment state-level information exchange initiatives. As a network-of-networks, the network based on the Common Agreement allows states to build upon existing structures and connections. Less burdensome exchange allows for broader participation across provider types, including those not yet connected to exchange or with less sophisticated technology on board. More efficient connection across HINs will broaden the scope of information available and make it easier to share information across state lines. States with more than one regional health information exchange or health information network may consider how TEFCA can support their state interoperability priorities, such as establishing shared services.

The Basics of the Network Based on the Common Agreement

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

The Common Agreement will provide a single set of rules that address permitted data uses, privacy and security policies that must be followed, breach notification requirements, and other policies that must be in place before data can flow. It is important to note that the Common Agreement will not supersede or override state or local laws, such as those governing privacy or public health reporting. The TEFCA policies will not be inconsistent with existing federal laws and rules, such as HIPAA, and other existing laws at the state and local levels.

The technical standards underlying this network-of-networks approach will connect Qualified Health Information Networks (QHINs) to serve as the high-capacity infrastructure to share electronic health information across the entire nation—with all needed privacy and security protections and in line withapplicable laws. QHINs will be the central connection points within the network based on the Common Agreement, responsible for routing queries,responses, and messages among participating entities and individuals. Members of participating HINs will be able to request and receive patient information from QHINs.

Each QHIN will voluntarily enter into a contractual agreement with the RCE by signing the Common Agreement, which describes the rules for the network-of-networks. Some provisions of the Common Agreement will flow down to other   entities, such as health information exchanges, hospitals, or other entities participating in the network. 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 and authentication. The QTF will include a standards-based approach to directory services—a challenging aspect of exchange. Exchangewithin a given QHIN will generally be covered by the QHIN’s participant agreements and technical requirements, in line with the Common Agreement. Implementation timelines will take into account the need to modify existing agreements.

Considerations for States and Public Health

  • State-level privacy policies that may differ from and supersede those within the Common Agreement, such as consent, special classes of data that require special treatment (such as HIV status or behavioral health information), and an individual’s right to either opt-in or opt-out of information exchange.
  • Public health laws across states and jurisdictions may include rules about the information that can be shared. In addition, there may be programmatic rules for specific public health programs, such as required data elements, messaging formats, access roles, and data storage restrictions.
  • Most state governments and public health agencies have an existing set of mechanisms for sharing health information. TEFCA can help advance these needs by supporting automated public health reporting that may be supported or made more efficient through connection to the network based on the Common Agreement. State and regional health information exchanges can connect whether they choose to become a QHIN or connect to one.
  • Additional funding may be needed to support modernization of information systems and connectivity. States should consider federal sources, such as Medicaid Enterprise Federal Financial Participation (FFP), for building and operationally supporting interoperability networks, including networks connected to network based on the Common Agreement.
  • Review the Common Agreement, QTF and the educational materials on the RCE website. Identify whether any state and local programmatic requirements may need to be changed or modified to leverage future participation in network based on the Common Agreement.
  • Consider existing health information exchange infrastructure and technical capability and what may need to be modernized.
  • Analyze the attributes of a HIN or QHIN that would support their information exchange goals.
  • Investigate funding needs and sources.


On the Radar

As we continue to develop the Common Agreement, 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.
  • Development of transparent and efficient application and onboarding processes for QHINs.
  • Development of educational materials and opportunities to keep stakeholders informed and engaged.

The RCE is committed to taking a practical approach to implementation that will seek to minimize burden and build on what is working today. We encourage all stakeholders to engage with us as the community works together to realize nationwide health information exchange.

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