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 21^st 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.
    • The ONC has selected The Sequoia Project as the RCE.
  • 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.

In July 2024, House Committee on Administration Ranking Member Joseph D. Morelle (D-N.Y.), released a critical report titled Voting for Native Peoples: Barriers and Policy Solutions. This report underscores the ongoing struggles faced by Native communities in exercising their right to vote—a fundamental right that has been undermined for decades.

The Report provides a detailed history of the oppression and discrimination against Native peoples by the United States federal government, highlighting physical, identification, language, and systematic barriers that continue to hinder full participation in the electoral process. It also highlights the efforts of state and local governments to dilute Native votes and engage in racial gerrymandering, stating that “lawmakers further dilute Tribal citizens’ voting strength by packing supermajorities of Native voters into single electoral districts, even where the community is large enough to constitute a majority and elect candidates of choice in more than one district.”

The report also calls for actionable solutions to the problems outlined. It advocates for the passage of key legislation, including the Native American Voting Rights Act, the Freedom to Vote Act (H.R. 11), and the John R. Lewis Voting Rights Advancement Act (H.R. 14), which aim to dismantle the barriers to voting and restore essential protections for Native voters. NCUIH endorsed the Native American Voting Rights Act in the 117^th Congress and supports the reintroduction of this legislation in a future Congress.

Key Findings and Policy Proposals:

Barriers to Voting for Native Peoples:

• Physical Barriers: The report highlights “Native Americans face substantial barriers to accessing in person voting and voter services, including voter registration and ballot drop boxes, due to extreme physical distances”.
• Language Barriers: “Few states and localities offer robust assistance in Indigenous languages, sometimes in violation of federal law.”
• Identification Barriers: “Several states have enacted, implemented, or enforced voter identification laws, including documentation requirements to register to vote and to cast a ballot in person or by mail, that abridge the right of Native peoples to participate fully and equally in the nontribal political process.”
• Systematic Barriers: “[The]federal government’s removal, reservation, assimilation, and termination policies of the nineteenth and twentieth centuries created systemic obstacles that compound the barriers Tribal citizens face to full and equal participation in the nontribal political process.”
• Residential Address Barriers: “Tribal members commonly use descriptive addresses, specifying where they live using highway or Bureau of Indian Affairs route numbers, mile markers, and other landmarks. Tribal members who rely primarily on descriptive addresses often face substantial obstacles when attempting to register to vote and cast a ballot. Most troublingly, in some instances, Tribal members have been completely barred from the political process or certain methods of voter registration when they attempt to use a descriptive address”.

Proposed Policy Solutions:

• The Frank Harrison, Elizabeth Peratrovich, and Miguel Trujillo Native American Voting Rights Act (NAVRA): this legislation would address many of the barriers to voting faced by Native peoples by establishing baseline, consistent standards for voting throughout Indian Country, ensuring that Native Americans no longer bear the burden of lengthy, costly litigation to defend and enforce their right to vote. NCUIH has endorsed this legislation.
• John R. Lewis Voting Rights Advancement Act (VRAA): this bill would restore important provisions of the Voting Rights Act that have been severely curtailed by the U.S. Supreme Court and other federal courts over the past two decades. The VRAA also strengthens Section 2 of the Voting Rights Act—a key pillar that allows plaintiffs, including Tribal nations and individual voters, to bring claims for vote denial and vote dilution.

For more details, read the full report here.

NCUIH Advocacy on Native Voting

NCUIH has taken several steps to address some of the barriers discussed in the report. In February 2024, NCUIH signed a letter of support for the John R. Lewis Voting Rights Advancement Act and endorsed the legislation. Additionally, NCUIH has worked closely with the National Urban Indian Family Coalition to Get Out The Vote and improve voter registration abilities at Urban Indian Organizations.

On August 05, 2024, Congresswoman Teresa Leger Fernández (D-NM-03) introduced the National Council of Urban Indian Health (NCUIH)-endorsed Telehealth for Tribal Communities Act of 2024 (H.R. 9271) which would make permanent a Covid 19 Public Health Emergency (PHE) temporary provision allowing audio-only telehealth services for Medicare beneficiaries receiving care through Indian health programs or urban Indian organizations (UIOs). Providing access to audio-only telehealth services allows patients to access care even when broadband access is limited or unavailable. Prior to the PHE ending in May 2023, IHS patients used audio-only services 60% of the time and video telehealth 39% of the time, demonstrating how valuable this provision is to patients. This legislation will help address the persistent challenge of accessing healthcare in Indian Country.

“The National Council of Urban Indian Health is pleased to endorse the Telehealth for Tribal Communities Act introduced by Representative Leger Fernandez. This legislation is critical to increase access to care for our American Indian and Alaska Native communities. Maintaining the Public Health Emergency’s Medicare reimbursement of audio-only telehealth demonstrates a commitment to addressing health disparities in Native communities. I urge Congress to swiftly pass this bill, which is critical to ensure our patients have continuous access to culturally competent care wherever they reside,” said Francys Crevier (Algonquin), CEO, National Council of Urban Indian Health. 

The bill was cosponsored by Congressman Raúl M. Grijalva (D-AZ-07), Congresswoman Gwen Moore (D-WI-04), and Congressman Raul Ruiz (D-CA-25)

This bill is also endorsed by the National Indian Health Board, National Congress of American Indians, Northwest Portland Area Indian Health Board, President Buu Nygren of The Navajo Nation, Health, Education and Human Services Committee (HEHSC) of the 25th Navajo Nation Council, Jemez Health and Human Services Department in New Mexico, American Telemedicine Association, and Alliance for Connected Care.

Next Steps

The bill was referred to the House Committee on Energy and Commerce and the House Committee on Ways and Means. It currently awaits consideration.

Resources

• Congresswoman Leger Fernández Press Release
• Bill Text
• One Pager and Section by Section