FAQ on TEFCA for Urban Indian Organizations

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1. What is TEFCA?

  • TEFCA was created by the Department of Health and Human Services (HHS) Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC) under the authority of the 21st Century Cures Act.
  •  The goals of TEFCA are:
    1. (1) to establish a universal governance, policy, and technical floor for nationwide interoperability;
    2. (2) to simplify connectivity for organizations to securely exchange information to improve patient care, enhance the welfare of populations, and generate health care value; and
    3. (3) to enable individuals to gather their health care information.
  • TEFCA is made up of two parts:
    • (1) The Trusted Exchange Framework (TEF), a set of principles to follow when participating in secure data exchange under TEFCA.
    • (2) The Common Agreement (CA), a standardized agreement that enables data sharing between TEFCA participants.
  • Combined, they are referred to as the “TEFCA,” which supports a nationwide exchange of Electronic Health Information (EHI) across disparate Health Information Networks (HINs). HINs are entities that serve as a network for health information across health care entities, electronic health record platforms, and other entities that store and share electronic health information.

2. What entities are involved in TEFCA?

  • The entities involved in TEFCA are:
    • The HHS Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC): the federal agency responsible for implementing TEFCA.
    • The Recognized Coordinating Entity (RCE): the entity responsible for the development, implementation, and maintenance of the Common Agreement and for the review of applications from HINs seeking to join TEFCA and become QHINs.
    • Qualified Health Information Network (QHIN): an HIN that has completed the application and onboarding process required by the RCE and is now “qualified” to share information within the TEFCA framework.
      • QHINs currently part of TEFCA include eHealth Exchange, Epic Nexus, Health Gorilla, KONZA, MedAllies, CommonWell Health Alliance, and Kno2.
    • Participants: persons or entities who are contracted with a QHIN and have agreed to participate in TEFCA under the Common Agreement. Participants can include health information networks; health information exchanges; individuals; providers; federal agencies; public health agencies; health plans and other payers; and health IT developers (e.g., electronic health records systems).
    • Subparticipants: persons or entities who use services provided by a Participant through sending and receiving Electronic Health Information. Subparticipants are often healthcare providers, health systems, ambulatory providers, and health IT developers.
    • Principal: a QHIN, Participant, or Subparticipant that is acting as a Covered Entity, Government Health Care Entity, Non-HIPAA Entity (NHE) Health Care Provider, a Public Health Authority, a government agency that makes a Government Benefits Determination, or an Individual Access Services Provider.
    • Delegate: a QHIN, Participant, or Subparticipant that has a written agreement, directly or indirectly, with a Principal authorizing the Delegate to conduct TEFCA Exchange activities for or on behalf of the Principal.

3. What role do UIOs play in TEFCA?

  • Under the TEFCA framework, a UIO whose EHR provider has contracted with a QHIN is considered a “Subparticipant.” The UIO’s EHR provider is a “Participant.”
  • In some cases, a UIO’s EHR provider may choose to become a QHIN and join TEFCA. This would then label any UIO that join TEFCA through this provider a “Participant.”
  • Additionally, a UIO can join TEFCA under any QHIN of their choosing and become a “Participant.” It does not have to be done through their EHR system.

4. How do UIOs become Participants/Subparticipants in TEFCA?

  • Each QHIN must agree to the terms of the Common Agreement.
  • The Common Agreement contains Terms of Participation which must be signed by each Participant and Subparticipant. These have also been referred to as “flowdown provisions.”
  • For example, if the EHR system a UIO uses is connected to an HIN that completes the process to become a QHIN under TEFCA, and the UIO’s EHR system then agrees to the terms of the ToP and becomes a Participant under TEFCA, then the UIO may have the option to sign the ToP to become a Subparticipant under TEFCA.
  • The signing of the ToP is also required if a UIO joins as a Participant under an EHR system that is acting as a QHIN, or directly through any QHIN currently part of TEFCA.
  • Signature of the ToP is only required if a UIO wants to join TEFCA’s nationwide health information exchange. UIOs are not required to join TEFCA, even if their EHR becomes a Participant in TEFCA or joins TEFCA as a QHIN.
  • If UIOs do not sign the ToP, they can still utilize health information technology, like the EHR system, but will not be able to participate in nationwide health information exchange through TEFCA.
  • If the EHR a UIO uses has joined a QHIN as a Participant, but the UIO has not been given the option to join the QHIN as a Subparticipant, it is recommended that the UIO reach out to their EHR for more information. UIOs can also reach out to QHINs directly for information about joining TEFCA.
  • Today, participation is voluntary, allowing UIOs flexibility to make the decision to join TEFCA. However, if any UIOs signed a previous sub-agreement to join TEFCA before July 1, 2024, they must agree to the updated ToP by December 27, 2024, to continue to participate in TEFCA.

5. How does health information exchange work under TEFCA?

  • Requests are made through QHIN-to-QHIN exchange and must be for one or more of the reasons outlined in the Exchange Purposes (XPs) and must follow the requirements outlined in the XP Standard Operating Procedure (SOP). These purposes include treatment, payment, health care operations, public health, government benefits determination, and individual access services (IAS).
  • For example, a UIO (as a Participant or Subparticipant) may initiate a QHIN Query to supplement or update a patient’s records they maintain. The UIO, now acting as a Principal, would request the Delegate contact their QHIN to initiate the query, under the specified XP code, to other QHINs who may be connected to entities (either a Participant or Subparticipant) that may have records for that patient. These entities could include a state health department, tribally operated hospital, or any facility that has been connected to TEFCA through their own QHIN.
  • The technical infrastructure that supports exchange of information is maintained by QHINs. Data is not stored by the QHIN, it is only exchanged between the two entities. Neither Participants nor Subparticipants actively participate in the process. Participants and Subparticipants only make requests or respond to requests made by other TEFCA entities.

6. Is TEFCA currently in effect?

  • Yes, TEFCA has been live since the fourth quarter of 2023 when the first QHINs went live with health information exchange.

7. Are there any anticipated changes to TEFCA?

  • TEFCA will continue to evolve, and we can anticipate changes in participation, exchange purposes, governance and documentation moving forward. Additional QHINs are already in the process of being approved.
  • Documents are still being updated to assist with implementation of TEFCA. The most recent updates were
    July 1, 2024, and August 6, 2024, but more updates will be provided later this fall. These updates can be found on the Sequoia Project’s website.
  •  In addition, the Sequoia Project holds webinars to provide an overview of updates, which includes a Q&A session for any potential questions.
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