TEFCA: The On-Ramp to Interoperability

The U.S. Department of Health and Human Services (HHS) has been given the colossal task of creating a Trusted Exchange Framework and Common Agreement (TEFCA) that supports a network-to-network exchange of health information nationally. No small order.

Sequoia Project selected

Early in September, the Office of the National Coordinator for Health Information Technology (ONC) selected  the Sequoia Project to serve as the Recognized Coordinating Entity (RCE) overseeing parts of the TEFCA project.

The intent of TEFCA is to provide a way for different health information networks to communicate with one another, and various interoperability groups whose work would be overseen by the Sequoia Project. The CommonWell Health Alliance plans to become one of many planned QHINs, which will agree to exchange data.

The Sequoia Project will also select and monitor the Qualified Health Information Network (QHIN) under its cooperative agreement with ONC, funded at $900,000 in the first year.

The documents released earlier for public comment were a second draft of the Trusted Exchange Framework (TEF), a second draft of the Minimum Required Terms and Conditions (MRTCs) for the trusted exchange of data, and the first draft of a QHIN Technical Framework.

These documents form the single Common Agreement that QHINs and other participants may adopt. The Common Agreement, which is expected to be finalized in 2020, will create the baseline technical and legal requirements for sharing electronic health information nationwide and scale across disparate networks.

In developing a TEFCA that meets the industry’s needs, ONC has focused on three goals:

  • Provide one “on-ramp” to nationwide connectivity;
  • Ensure electronic information securely follows you when and where it’s needed; and
  • Support nationwide scalability for network connectivity.

The Sequoia Project was formed in 2012 to advance interoperability, and has managed the eHealth Exchange, which has become the largest health information network in the U.S., as well as supporting the Carequality initiative.

A core responsibility for the Sequoia Project as the RCE will be to develop a Common Agreement that includes the Minimum Required Terms & Conditions Draft 2 and Additional Required Terms & Conditions developed by the RCE (ARTCs) and approved by ONC. The Common Agreement will be published on HealthIT.gov and in the Federal Register and finalized in 2020. It will then identify and monitor QHINs that voluntarily agree to sign and adopt the Common Agreement.

Serving as an on-ramp

Currently, regional health information exchanges in each state and other organizations support health information exchange. While these organizations have made progress in advancing interoperability, connectivity across health information networks (HINs) is limited due to variations in the participation and data use agreements that govern the exchange of data. This results in fragmentation and gaps in interoperability.

It also means that HINs, providers, health plans, and individuals participating in data exchange, are costly in accessing an individual’s data. 

Bridging data sharing differences

Through this effort, ONC will define the minimum required terms and conditions needed to bridge the differences among data sharing agreements that prevent the flow of electronic health information. The Sequoia Project as the RCE will develop additional terms and conditions necessary to operate the Common Agreement and meet the interoperability requirements of the 21st Century Cures Act.

Don Rucker, M.D., the national coordinator for health information technology, said the updated TEFCA considered more than 200 comments received. “The future Common Agreement, made possible by the steps we take today, will provide the governance necessary to meet the interoperability demands of diverse stakeholders, including patients, healthcare providers, and health plans,” Dr. Rucker said.

The draft’s response addresses stakeholder comments by making changes to the draft requirements that health information networks, who choose to participate, would have to follow. The changes include updating the purposes for exchanging information, adding a “push” method of data exchange, adding a technical framework for QHINs, and extending timelines for participating entities to implement changes required by the Common Agreement. These changes will help improve the flow of information between networks where needed and appropriate.


Part of the TEFCA project is the U.S. Core Data for Interoperability (USCDI) is a standardized set of health data classes and data elements for nationwide, interoperable health information exchange.

  • A USCDI Data Class is an aggregation of various data elements by a common theme or use case.
  • A USCDI Data Element at a granular level, is the exchange of a piece of data
    • For example, Date of Birth is a Data Element rather than its component Day, Month, or Year, because Date of Birth is the unit of exchange.

For more details, including data class descriptions and applicable standards supporting data elements, see USCDI v. 1

Effects on organizations

TEFCA will bring new levels of health information exchange needed across all entities (hospital systems, physician groups, care providers, and payers) in the industry. In addition to the exchange formats and technologies (HL7 FHIR-based messaging), healthcare businesses will need to assess the availability and accuracy of data used in TEFCA-based exchanges.

This will require robust data architectures, data models, and data services focused on making information available for exchange, while also focusing on data accuracy and quality. In addition, data integration services will need to be available to provide the mechanics behind a FHIR-based exchange of information.

Organizations will need to ask whether their data strategy supports the availability of information expected for a TEFCA-based exchange. If they have robust data integration services for reading that data, formatting into the JavaScript Object Notation (JSON) message formats needs to manage the successful transport of the message to external entities.

COE services

IQVIA’s Healthcare Technology practices provide consulting services to guide your organization into the next generation of health information exchange from enterprise information management strategies, data quality initiatives through data integration services and testing. We have the depth and knowledge to assist in standing up the new TEFCA health information exchanges that will bring new levels of interoperability to the industry.

The Healthcare Technology staff attend the TEFCA oversight and implementation meetings and are actively monitoring the progress.

To learn more about the IQVIA’s Healthcare Technology Strategic Planning & Digital Health practice, please reach out to Ted Marsh, vice president, strategic planning & digital health.