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On July 28, 2021, the Trusted Exchange Framework and Common Agreement (TEFCA) Recognized Coordinating Entity (RCE) published the draft of the Qualified Health Information Network (QHIN) Technical Framework.
The 21st Century Cures Act, signed by President Obama in 2016, calls on ONC to “develop or support a trusted exchange framework, including a common agreement among health information networks nationally.” To that end, the Trusted Exchange Framework and Common Agreement (TEFCA) includes the trust policies and practices and a “Common Agreement” that will establish a governing approach for exchange among Qualified Health Information Networks (QHINs). ONC awarded a cooperative agreement to The Sequoia Project to serve as the Recognized Coordinating Entity (RCE) to provide the legal and technical framework to support nationwide exchange based on the Common Agreement. The goal of TEFCA is to establish a floor of universal interoperability across the country. TEFCA will define the baseline legal and technical requirements for information sharing on a nationwide scale.
The network based on the Common Agreement will create simplified connectivity for individuals, health care providers, health plans, and public health agencies as well as other stakeholders.
The QHIN Technical Framework (QTF) supports the core QHIN-to-QHIN exchange by specifying the functional and technical requirements that each QHIN must fulfill under the Common Agreement and to meet the requirements of the Standard Operating Procedures (SOPs), which will be created by the RCE and implement the Common Agreement. These requirements include, among others, privacy and security steps, approaches for identifying and authenticating exchange participants, how to conduct patient discovery and identity resolution, as well as support for required exchange protocols. QHINs will be responsible for routing queries, responses, and messages to and from their participants. They will be the foundational network nodes supporting exchange among networks. Health information networks must satisfy rigorous eligibility requirements in order to be designated as a QHIN by the Recognized Coordinating Entity (RCE).
The QTF focuses primarily on QHIN-to-QHIN exchange and, as such, must support at least two forms of information exchange among authorized parties (consistent with applicable law and the Common Agreement):
In addition, the RCE will maintain a directory of exchange participants connected to each QHIN so that other QHINs and participants can direct their queries or message deliveries appropriately. QHINs will be required to support QTF Directory requirements for maintaining their directory entries.
Consistent with the philosophy of building on what works, the technical and functional requirements described in the QTF reflect many of the technologies and standards used for network-based health information exchange today, including those used by many community, state, and nationwide exchange networks. In general, the information shared within the QHIN-to-QHIN exchange builds on the Health Level Seven (HL7®) Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) Draft Standard for Trial Use Release 2.1 (C-CDA 2.1) document format. This includes data defined as part of the United States Core Data for Interoperability Version 1 (USCDI v1) with allowance for flexibility to further expand the content of messages to support a multitude of use cases.
The QTF also specifies high-level functional requirements that QHINs will need to support within their health information networks. So long as QHINs are able to achieve the required functional outcomes within their networks and satisfy the privacy, security, and other requirements of the Common Agreement, they generally have the operational flexibility to select appropriate standards, architectures, and approaches consistent with the needs of their business environments.
Newer standards, such as HL7’s Fast Healthcare Interoperability Resources (FHIR®), will be specified in future versions of the QTF. QHINs will be required to follow such standards only after the approval of QTF updates through the governance process required by the Common Agreement. The RCE seeks stakeholder input into developing a TEFCA FHIR Roadmap. The TEFCA FHIR Roadmap is intended to layout the scope, timing, and transition requirements for QHIN-to-QHIN exchange via FHIR. The TEFCA FHIR Roadmap will be released with the final versions of the QTF and the Common Agreement after careful deliberation and industry engagement regarding the complexities of deploying FHIR in a network environment.
The QTF document lays out the detailed expectations and requirements for:
 The Common Agreement will provide the governing approach necessary to scale a functioning system of interconnected QHINs. The Common Agreement will be a legal agreement that the Recognized Coordinating Entity (RCE) and QHINs will sign. Some provisions of the Common Agreement will flow down to other entities, such as QHIN Participants and Subparticipants, via contracts.
The RCE is looking for feedback on the entirety of the QTF. The stakeholder engagement process will include webinars and a web form that will enable interested parties to learn more about and share their input.
In addition to comments on the content included in the QTF, the RCE seeks input on the following specific questions:
1. Should the QTF include QHIN Message Delivery? If you believe QHIN Message Delivery should be included, how should it be technically specified? Note: if QHIN Message Delivery is excluded from the first version of the QTF that would mean QHINs would not be required to support QHIN-to-QHIN message delivery during the initial go-live under the Common Agreement. To facilitate better understanding of the public feedback, the RCE requests that responses consider the following three options:
2. What elements should be included in a TEFCA FHIR Roadmap to provide predictability and a clear direction for QHIN-to-QHIN exchange regarding the implementation of FHIR for QHIN Query, QHIN Message Delivery, and for enabling FHIR data to be used by Health IT systems?
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