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TEFCA Gets Ready For Its Moment in the Spotlight

Analysis  |  By Eric Wicklund  
   January 30, 2024

With version 2.0 now supporting FHIR-based exchange, Mariann Yeager of the Sequoia Project says the final draft of standards for nationwide interoperability should be unveiled by the end of March.

Healthcare organizations with a vested interest in interoperability should be taking a close look at version 2.0 of the Trusted Exchange Framework and Common Agreement (TEFCA), which now supports FHIR-based exchange.

The Sequioa Project, the non-profit appointed by the federal government to be TEFCA’s Recognized Coordinating Entity (RCE), unveiled version 2.0 earlier this month alongside several related documents and is accepting public comments through February 5. The groups’ CEO and RCE lead, Mariann Yeager, says a final version should be available by the end of March.

The government-supported effort to create nationwide interoperability standards has been more than two years in the making, coming out of the 21st Century Cures Act. This past December, five healthcare organizations were the first to be certified as Qualified Health Information Networks (QHINs), giving them the standing to support data exchange.

Yeager says the biggest take-away from version 2.0 is federal recognition of FHIR (Fast Healthcare Interoperability Resources), the HL7 standard that defines how healthcare information can be moved between disparate platforms.

“The most important thing for people to understand is that version 2.0 was revised to support FHIR-based exchange,” she told HealthLeaders. “There are new use cases to support healthcare operations and public health. The other thing is it does permit health systems that participate in TEFCA-based exchange to connect to multiple QHINS, to the extent that they support multiple data sources.”

Yeager also said she expects more conversation around health systems that appoint another entity to exchange healthcare data.

[See also: Providence Unveils FHIR Tool for seamless Data Transfer.]

Writing in the HealthITbuzz blog earlier this month, Chris Muir and Alan Swenson of the Health and Human Services Department’s Office of the National Coordinator for Health IT (ONC) said the unveiling of five QHINs and the release of TEFCA version 2.0 “continue the momentum” toward a nationwide interoperability platform this year.

“In the short-term, ONC and the TEFCA RCE anticipate ‘facilitated FHIR’ exchange beginning to be implemented as part of TEFCA exchange as early as the first quarter of calendar year 2024 connected to the release of Common Agreement Version 2,” they said. “As in Version 1, Version 2 of the Roadmap describes facilitated FHIR exchange in which Qualified Health Information Networks (QHINs) provide the network infrastructure to support FHIR API-based exchange between TEFCA Participants and Subparticipants from different QHINs.”

“Specifically, if a TEFCA Participant or Subparticipant wants to obtain a patient’s data using FHIR, they will go to their QHINs to determine who has the patient information,” Muir and Swenson continued. “Patient discovery will take place through the QHIN-to-QHIN interaction, including discovery of the FHIR endpoints for those that have the patient data. The initiating Participant or Subparticipant will then directly (i.e., without going through the QHIN) and securely query each of those endpoints.”

Yeager says she’s excited to see data exchange scaled up to a national level.

“There are different ways in which FHIR is being used,” she said, noting that TEFA had support content exchange and is now embracing native FHIR. “We’re talking about … facilitating FHIR-based exchange with each other. What that enables is nationwide scale. This is an unprecedented opportunity in the US to support FHIR-based exchange at such scale.”

The five QHINs, MedAllies, the eHealth Exchange, Epic Nexus, Health Gorilla, and the KONZA National Network, have been exchanging data since TEFCA officially went live in December. Yeager says “several others” are going through the process to become designated QHINs and other healthcare organizations are preparing to take that route as well.

“They really see FHIR as an important functionality,” she said of the first QHINS.

Aside from gathering information through the public comment period, Yeager says the Sequoia Project will be scheduling public information webinars as well as targeted feedback sessions over the next several weeks to prepare the final version.

Muri and Swenson of the ONC said there are more goals ahead.

“Looking forward, the updated Roadmap describes two more phases of FHIR implementation beyond facilitated FHIR exchange,” they wrote in the blog. “The next phase, QHIN-to-QHIN FHIR Exchange, [will] enable QHINs to leverage FHIR-based exchange for exchange between QHINs while continuing to support non-FHIR approaches within the QHINs’ internal networks.”

“The last phase, End-to-End exchange, would permit a Participant/Subparticipant to seamlessly exchange FHIR data between themselves and other network members through the QHINs and multiple other intermediaries both within a QHINs’ network and through the TEFCA-governed network,” they added.

Yeager expects interoperability to be an ever-evolving process.

“TEFCA is really going to be evolutionary,” she said. “We will definitely be learning as we go, learning and adjusting. … You learn by putting things into practice.”

Eric Wicklund is the associate content manager and senior editor for Innovation at HealthLeaders.


The Sequoia Project, the ONC-appointed Recognized Coordinating Entity for TEFCA, has unveiled version 2.0, along with several associated documents, and is taking public comment through February 5.

The latest version supports FHIR-based exchange, a key element to the exchange of data between disparate platforms.

A final version of TEFCA is expected by the end of March.

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