TEFCA-Ready HIEs: How Health Systems Are Preparing for the Next Wave of Interoperability Rules
The Trusted Exchange Framework and Common Agreement is the federal blueprint for a nationwide “network of networks” to share electronic health information. Mandated by the 21st Century Cures Act and managed by ONC with the Sequoia Project as the Recognized Coordinating Entity, TEFCA establishes a common legal and technical framework so that any authorized provider can exchange health data across the country.
In practice, TEFCA creates a standardized “on‑ramp” to connect disparate health information networks (HINs) – including Health Information Exchanges, EHR-vendor networks, and public health systems – under uniform “rules of the road.” Its goal is to streamline secure data exchange at the point of care, improve patient access to records, and enhance care coordination nationwide.
TEFCA’s non‑binding trust principles – standardization, openness, cooperation, nondiscrimination, privacy, security, access, and equity – guide the design of all TEFCA policies and technical specifications.
TEFCA comprises four main components:
- The Trusted Exchange Framework,
- The Common Agreement,
- The Qualified Health Information Network Technical Framework, and
- Standard Operating Procedures.
Under this model, networks that meet TEFCA requirements become QHINs – essentially “super-HIEs” – which in turn enable hundreds of hospitals, clinics, and other entities to access nationwide exchange services.
Implications for Interoperability
The rise of TEFCA has major implications for health IT interoperability. By binding all participating networks to common policies and standards, TEFCA ensures that a clinician can query patient records from anywhere in the country through a trusted portal. For example, clinicians in rural or underserved areas – historically on the periphery of data exchange – can tap into Epic’s Nexus QHIN or an HIE QHIN and reach health data that was previously siloed.
Stanford Health Care notes that having a patient’s “full story at the point of care” leads to better diagnoses and fewer duplicate tests. Likewise, patients themselves gain unified access to their records: apps connecting via TEFCA’s “individual access services” model can retrieve patient data from any participating provider, giving patients a single on‑ramp to all their records.
According to industry experts, providers should begin TEFCA preparations now, even before TEFCA is fully operational. An AHIMA/Oracle Cerner panel advised hospitals to “connect with networks that are moving towards TEFCA” rather than wait. Indeed, many health systems have already committed to joining through their EHR vendors. Epic – whose CommonWell/Carequality network became a QHIN – announced that 24 leading health systems were accepted into its TEFCA testing cohort.
Epic reports that nearly all of its 2,000 hospital customers plan to participate in TEFCA as soon as possible. Oracle Health likewise leveraged its CommonWell Alliance network to become a QHIN: Oracle’s QHIN connects directly to all other QHINs, normalizes incoming patient data on the fly, and delivers it into providers’ workflows with no extra configuration. These vendor-led QHINs effectively offer health systems an easy “opt-in” path to TEFCA by upgrading their existing interoperability tools.
Independent HIEs and state/regional networks
At the same time, independent HIEs and state/regional networks are gearing up. Many have formed or joined alliances to participate in a QHIN together.
- For example, Contexture – the large nonprofit HIE serving Arizona and Colorado – plans to serve as a Participant in eHealth Exchange’s QHIN, leveraging its existing connection to eHealth Exchange.
- Contexture is part of the Consortium for State and Regional Interoperability, a coalition of five major HIEs, all of which have announced intentions to join TEFCA via eHealth Exchange.
In practice, Contexture will offer TEFCA connectivity as a new service line: Customers can opt in, become subparticipants under Contexture’s QHIN link, and sign an addendum to their HIE participation agreement that flows down key Common Agreement requirements.
Similar scenarios are unfolding elsewhere – public health networks, payer networks, and even federal agencies are aligning with existing HIE QHINs to enable data sharing under TEFCA.
Technical Framework and Standards
Defining the QHIN Technical Framework
Standards alignment and technical readiness are at the heart of TEFCA. The QHIN Technical Framework specifies the minimum interoperability capabilities a network must have to serve as a QHIN. In practice, TEFCA builds on the existing HIE playbook: it relies on Integrating the Healthcare Enterprise profiles for cross-community exchange, while also driving adoption of modern FHIR-based APIs.
For example, QTF v2.0 explicitly adds “Facilitated FHIR” as a required exchange modality – including use of FHIR R4 resources and the HL7® FAST UDAP security guide for OAuth client registration.
Upgrading Systems for TEFCA Readiness
In concrete terms, becoming TEFCA-ready means upgrading EHRs, HIE platforms, and identity services to support these standards. By federal regulation, all certified EHR systems were required to implement standardized FHIR Release 4 APIs by the end of 2022, enabling patient-data APIs and record-finder queries. However, multi-network FHIR exchange is still in its infancy. TEFCA aims to accelerate it: the ONC’s FHIR Roadmap notes that while FHIR is widely supported within individual organizations, its use “in multi-networked environments in standardized ways” is nascent. The TEFCA specifications include new FHIR operational requirements to drive broader adoption.
Ensuring Security and Reliability Across Networks
Network security and reliability are equally mandated. QHINs must maintain secure, stable connections to all their participants and peer networks. For example, the QTF states that “each QHIN MUST be able to connect successfully… to all of its Participants; any failure… must be addressed in the shortest time practicable”. In practice, this requires enterprise-grade infrastructure: cloud platforms are popular. Networks must implement PKI for trust, OAuth2.0 for FHIR APIs, and the emerging UDAP standards for client registration and JWT trust. TEFCA’s security framework also demands robust audit logging, breach response procedures, and compliance with privacy laws.
Meeting Compliance and Trust Requirements
For instance, a QHIN’s Participants and Subparticipants are required to adhere to all HIPAA/HITECH security and privacy rules, as well as state laws. In short, health systems must ensure their IT architecture and policies meet TEFCA’s stringent trust requirements in addition to legacy HIPAA compliance.
Related: Next-Generation HIE Platforms: Combining Cloud, FHIR, and AI for Intelligent Data Exchange
Data Governance and Privacy
Beyond technology, governance and legal frameworks are crucial. All entities participating in TEFCA-bound exchange must abide by the Common Agreement – a legal contract that flows down obligations through QHINs to participants.
This includes adhering to TEFCA’s Trust Principles and to specific Standard Operating Procedures on topics like consent management, patient matching, and use-case permissions. For example, TEFCA requires mechanisms for patients to access and contribute their own records in compliance with ONC rules. It also mandates a national Provider Directory to help find data and common coding vocabularies.
Health systems and HIEs must update their governance policies and agreements accordingly. Participating organizations will sign TEFCA addenda to their HIE or network agreements, incorporating the required terms of the Common Agreement. For instance, as Contexture plans, participants who opt into TEFCA will sign an addendum with the flow-down provisions from Contexture’s QHIN agreement. HIEs emphasize that TEFCA is not meant to replace local consent/privacy regimes but to complement them.
In fact, many regional HIEs pride themselves on advanced patient matching and fine-grained consent capabilities – assets they will bring into the TEFCA ecosystem. A key selling point for local HIEs is that they can enforce granular consent controls that a national QHIN might not. Similarly, local HIE governance bodies often reflect community values around data use, which can help build trust in TEFCA.
Preparing to Be TEFCA-Ready
In practical terms, how are health systems and HIEs preparing?
Align with one or more QHINs
First, organizations should align with one or more QHINs. Large health systems often join via their EHR vendor, while others connect through an HIE that is or will become a QHIN.
- For example, Contexture and other HIEs are forming TEFCA service lines: once their preferred QHIN partner is live, they will give customers an “opt-in” option to join that national network.
- Many HIEs will leverage existing interfaces – for instance, continuing to use their eHealth Exchange connections – to minimize new integration work.
- Health systems should monitor which QHINs emerge in their regions and plan connectivity accordingly.
Modernize infrastructure and interfaces
Second, IT teams must modernize infrastructure and interfaces. This includes deploying FHIR servers or APIs in their EHR/HIE platforms if not already present, and upgrading legacy exchange endpoints to meet TEFCA specifications. Some concrete steps are:
- Ensure IHE cross-community document endpoints are operational
- Establish OAuth2.0 authorization servers for app-to-app exchange, and
- Implement UDAP clients for trusted app registration.
Hospitals should inventory their data sources and ensure they can expose the needed FHIR resources or HL7v2 feeds for shared data. Many organizations are moving toward cloud-based HIE middleware or integration platforms to handle the increased traffic and orchestrate routing.
For example, Oracle’s TEFCA QHIN automatically “normalizes” data before feeding it into Oracle EHRs, sparing clinicians from manually reconciling records. Health systems without deep IT resources may rely on their HIE or EHR vendor to provide similar back-end services.
Data governance and privacy practices
Third, aligning data governance and privacy practices is vital. Hospitals and clinics must review their patient consent policies to ensure they permit the new kinds of exchange TEFCA enables. They should update business associate agreements and consider any state-specific privacy rules.
Many HIEs already maintain opt-out registries and fine-grained consent, which can be extended to TEFCA contexts. Networks will also need to integrate TEFCA-required patient attribution and consent artifacts. It’s recommended that IT and compliance leaders participate in the ongoing Sequoia Project/SOPs discussions to stay current on governance requirements.
Finally, operational readiness is key. Hospitals and HIEs should create a TEFCA readiness roadmap:
- Form a governance committee to oversee TEFCA activities.
- Train staff and vendors on TEFCA concepts.
- Negotiate connectivity contracts with chosen QHINs.
- Test data exchanges on pilot use cases (for example, send/receive a CCD from an out-of-state hospital).
- Monitor performance and compliance.
A useful checklist of steps might include:
- Join or contract with an approved QHIN.
- Update EHR/HIE systems to support required standards.
- Establish robust patient identity resolution services.
- Ensure all privacy/security controls meet TEFCA’s Common Agreement obligations and HIPAA/HITRUST practices.
- Sign the Common Agreement flow-down addendum and any Participant/Subparticipant Terms of Participation.
- Engage in TEFCA onboarding and testing processes.
By taking these steps early, providers can tap into TEFCA’s benefits as soon as networks go live. As one expert panel noted, “Providers should not wait until TEFCA is fully operational to begin preparations”. Indeed, the early QHINs are already operational and exchanging data. Being TEFCA-ready will position a hospital or HIE to easily scale data exchange nationally, improve care quality, and meet emerging regulations.
Related: FHIR, TEFCA & UDS+: How Enterprise-Scale Health Systems Are Gearing Up
CapMinds TEFCA-Ready Interoperability Service Solutions
Preparing for TEFCA demands more than technical upgrades, it requires a partner who understands interoperability, compliance, and nationwide exchange at scale.
CapMinds delivers end-to-end digital health technology services designed to help health systems, HIEs, and provider networks achieve full TEFCA readiness with confidence.
Our TEFCA-focused service offerings include:
- TEFCA & QHIN Connectivity Enablement
- FHIR API Development & Modernization
- HIE Platform Modernization Services
- Cloud-Based Integration & Middleware Services
- Identity, Security & UDAP/OAuth2.0 Implementation
- Data Governance, Consent Framework, and Compliance Services
- Ongoing Interoperability Support, Monitoring, and Optimization — and More
With CapMinds, you get a trusted interoperability partner who can upgrade your infrastructure, streamline multi-network exchange, reinforce HIPAA/HITECH compliance, and accelerate your organization’s journey toward TEFCA adoption.
Ready to become TEFCA-ready? Let’s build your nationwide interoperability roadmap together.
