- The ONC health data exchange framework — Trusted Exchange Framework and Common Agreement (TEFCA) — may cause short-term cost increases and additional levels of complexity for health information exchanges but will ultimately be worth the effort, according to HIMSS Senior Director of Federal and State Affairs Jeff Coughlin.
In a recent blog post, Coughlin offered his initial thoughts to the HIE community about ONC’s Trusted Exchange Framework and Common Agreement (TEFCA) draft designed to create a nationwide, voluntary network-of-networks for improved interoperability and health data exchange. The draft is currently open for public comment until February 20.
TEFCA is a set of policies, procedures, and standards intended to serve as a way to build on existing health information networks (HINs) to create a single on-ramp for health data exchange for provider organizations, EHR systems, and other stakeholders.
While the draft framework has been laid out, the Common Agreement is slated for development over the next year. According to an ONC media call on TEFCA, the federal agency will choose a Recognized Coordinating Entity (RCE) from the private sector to further build out the framework into a single set of guidelines and technical standards comprising the Common Agreement. HINs can agree to follow requirements laid out in the Common Agreement to become qualified HINs (QHINs).
“TEFCA capitalizes on the significant progress that the community has made over the last several years to share patient health information and provides the guard rails that qualified HINs should follow to engender trust amongst the community to expand information sharing even further,” stated Coughlin.
Like many stakeholders, Coughlin sees TEFCA as a necessary step toward enabling nationwide interoperability. However — given TEFCA is voluntary — it is likely some HINs will not feel motivated to take on the costs and added requirements that come with entering into the Common Agreement. As a result, there will need to be a compelling business case driving an HIN to become a QHIN.
“Most likely, market forces will compel HINs to want to become qualified HINs and abide by the principles and procedures outlined in TEFCA,” said Coughlin. “However, it’s unclear what enforcement mechanisms exist to keep HINs aligned with the TEFCA guidance.”
Though the enforcement mechanisms keeping QHINs compliant with TEFCA have not been explicitly established, the RCE will have oversight, enforcement, and governance responsibilities.
In addition to TEFCA, ONC is also currently working on drafting a proposed regulation for the information blocking provisions in the 21st Century Cures Act.
“21st Century Cures included civil monetary penalties up to $1 million per violation for networks, developers, or exchanges that block information,” wrote Coughlin.
In combination with TEFCA, the information blocking provisions should provide a firm enforcement mechanism to ensure QHINs comply with requirements, he maintained.
“It is likely that ONC will use the information blocking rule to point to their work on TEFCA when discussing definitional requirements related to what is not information blocking,” said Coughlin. “For instance, ONC could propose something along the lines that if a healthcare community stakeholder was fully participating in and partnering with a qualified HIN, such an entity could not be considered an information blocker.”
The information blocking rule will also address the conditions of certification for health IT developers, voluntary certification of health IT for pediatric health providers, and voluntary attestation for HINs about their adoption of TEFCA.
“The work occurring now on TEFCA is providing the foundation for the further required action in the upcoming proposed rule,” clarified Coughlin.
Coughlin also noted that TEFCA is fully aligned with HIPAA regulations to ensure secure health data access and exchange.
Finally, Coughlin pointed out the framework and common agreement will require many in the HIE community to update their participation agreements. These updates will likely lead to increased complexity, time expenditures, and costs.
“I would characterize participation agreement revisions in the short-term pain for long-term gain category, but if the market moves in the direction that ONC is intending and only a small number of qualified HINs (~10) come into existence, there will be a lot of work that has to occur to update these agreements across the entire community,” stated Coughlin.
Additionally, Coughlin raised the question of who will pay for TEFCA implementation and execution. ONC provided only general descriptions of the attributable costs, attributable services, and reasonable allowance costs that will come with becoming a QHIN.
“ONC’s approach is to let the market sort out how much providers, vendors, payers and other end users will have to pay to participate,” he wrote. “My concern is that the expanded responsibilities of qualified HINs will lead to multiplied required costs and that those costs have to be passed down to providers and ultimately to patients.”
While many questions remain, TEFCA is still in its developmental stages, and ONC and other stakeholders will continue to modify the framework over the next year or so. The information blocking proposed rule will help to provide some additional clarification in the near future.
“The upcoming proposed rule from ONC with information on what does not constitute information blocking will help refine what’s really required of all health system participants in terms of exchanging health data,” Coughlin concluded.