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TEFCA Advocates Urge Patience—And Preparedness—As Interoperability Plan Moves Forward

Analysis  |  By Eric Wicklund  
   October 11, 2023

Jim Jirjis, HCA Healthcare's CHIO, says critics of the ONC's proposed data exchange framework are missing the point that the framework is an ongoing process, and that revisions will be made as healthcare executives offer their opinions.

Interoperability in healthcare is no longer an "if," but a "when," and health system CIOs, CTOs, and even CEOs would do well to include that in their strategic plans. That includes laying the groundwork to adopt the Trusted Exchange Framework and Common Agreement (TEFCA), proposed by the Office of the National Coordinator for Health IT (ONC).

Some critics, including former ONC chief Donald Rucker, now chief strategy officer for digital health software company 1upHealth, have criticized TEFCA, saying the proposed framework for interoperability will do more harm than good. But Jim Jirjis, chief health information officer for HCA Healthcare and a member of the Health Information Technology Advisory Committee (HITAC) for ONC, says those concerns are overblown.

"What ONC is developing is a glide path to interoperability," says Jirjis. "It's a long path, and I'm very impressed with what they're doing. We need to be careful and practical."

TEFCA was authorized by Congress through the 21st Century Cures Act, with version 1 published by the ONC in January 2022 and updated that April. Its goal, according to the ONC website, "is to establish a universal floor for interoperability across the country."

Jim Jirjis, chief health information officer, HCA Healthcare. Photo courtesy Jim Jirjis.

"The Common Agreement will establish the infrastructure model and governing approach for users in different networks to securely share basic clinical information with each other—all under commonly agreed-to expectations and rules, and regardless of which network they happen to be in," ONC says. "The Trusted Exchange Framework describes a common set of non-binding, foundational principles for trust policies and practices that can help facilitate exchange among HINs."

Jirjis says critics are jumping too quickly on parts of the proposal that will likely be amended when the ONC releases the next draft—which he expects to be this year.

"Some expect TEFCA and [HL7's FHIR (Fast Healthcare Interoperability Resources) standard] to be automagical,” says Jirjis, combining the words automatic and magical. "They're correct in that we want a world where one day everyone will be using [this technology]. But to get there takes a lot of cost. And a lot of people are going to have to retool their systems to get there. It's going to take a while."

To counter the negative comments surrounding TEFCA, Steven Lane, MD, MPH, a former clinical informatics director at Sutter Health who's now chief medical officer for Health Gorilla, and Dave Cassel, a former Epic engineer and executive director of the Carequality interoperability initiative who now serves as Health Gorilla's chief customer officer, sent HealthLeaders a document refuting four of the most common misconceptions.

  1. Patient access is limited.

The first is that the ONC's proposal for an information blocking exception for TEFCA participants would hinder patient access to medical information.

"Quite the opposite," the two said. "TEFCA clearly and unequivocally supports enabling individuals to access their own health information. It mandates all participants to respond to Individual Access Services (IAS) queries made under TEFCA, ensuring that patients have digital access to their health information. ONC did propose an information blocking exception for TEFCA participants that was not well received and might have inadvertently disincentivized TEFCA participation. This feedback was recognized in the public comments on the proposed rule, and ONC is unlikely to include the initially proposed exception in the final rule."

  1. HIE is outdated.
    Regarding comments that IHE-based document exchange, which TEFCA would support, is underutilized and outdated, Lane and Cassel said "the vast majority of current health data exchange" is based on these guidelines, and they're working fine.

"It is the engine behind all of the success we've had in establishing national interoperability," they added. "The first version of TEFCA intentionally incorporated the current dominant transaction pattern so as to minimize industry disruption and to garner early voluntary adoption. IHE-based exchange was the right move to get providers and other participants in the healthcare ecosystem on board."

       3.     There's a limit on FHIR usage.

Critics have also argued that TEFCA doesn't use FHIR and limits the potential of FHIR-based exchange.

"The initial use of IHE-based document exchange for QHIN-to-QHIN [Qualified Health Information Network] exchange does not in any way restrict TEFCA participants from leveraging FHIR," Lane and Cassel said. "Participants can utilize FHIR exchange with their QHIN or between participants using the same QHIN. Moreover, the Recognized Coordinating Entity (RCE) has a transparent plan to integrate FHIR-based exchange in the second version of the QTF and CA, with meetings being scheduled now and implementation expected by early 2024."

  1. Does not compute!

Finally, Lane and Cassel say the comment that data within C-CDA [Consolidated Clinical Document Architecture] documents, which will be exchanged over TEFCA, are "non-computable" is incorrect.

"The fact is that the vast majority of discrete, computable, interoperable health data is exchanged today using C-CDA documents, which serve as flexible containers facilitating the transmission of many discrete and computable elements," they said. "We're talking about billions of documents and hundreds of billions of data points every year, leveraged by providers, analyzed by administrators, and retrieved by patients. Providers, public health agencies, and others routinely extract computable data from C-CDA documents to populate EHRs and drive analytical insights to improve patient care."

Jirjis says health system leadership should be familiarizing themselves with the latest TEFCA draft and developing an interoperability strategy, much like the Indiana Health Information Exchange has done in creating the Indiana Network for Patient Care. It's important, he says, to lay that groundwork now.

"Many CEOS and CIOs are consumed with how they’re going to survive in this increasingly automated age," he says. "They don't realize the improved quality and reduced costs of getting [interoperability] right."

“What ONC is developing is a glide path to interoperability. It's a long path, and I'm very impressed with what they're doing. We need to be careful and practical.”

Eric Wicklund is the associate content manager and senior editor for Innovation, Technology, and Pharma for HealthLeaders.


The ONC released the first draft of the Trusted Exchange Framework and Common Agreement (TEFCA) in 2022 and is expected to release an updated version soon.

Advocates say the path to nationwide healthcare interoperability needs to be carefully planned, so that health systems have time to adopt the framework and fit it into their organization.

CEOs and CIOs need to be prepared to spend time and money developing an interoperability strategy that aligns with TEFCA.

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