- As the public comment period for the ONC Trusted Exchange Framework and Common Agreement (TEFCA) draft comes to a close, stakeholders are revealing differences in opinion about the framework’s approach to health data exchange.
While most stakeholders applauded TEFCA upon its release, concerns about the framework’s complexities, costs, and lack of clarity are beginning to surface.
For its part, the American Medical Informatics Association (AMIA) largely supports the framework’s goal to develop a network-of-networks approach to health data exchange. In its letter, AMIA recognized the current state of health data exchange is expensive, burdensome for clinicians, and unsatisfactory for the purposes of digitizing patient care.
“At a national level, the health system simply cannot optimize nationwide investments in health IT based on push-only exchange and contractual relationships that must be created anew for each step in the referral chain,” stated AMIA in its comments. “In tandem, the TEFCA and USCDI represent a new paradigm for our national health IT infrastructure.”
However, AMIA recommended ONC develop a comprehensive timeline for TEFCA implementation over the next three years that includes pilot tests for specific aspects of the framework. AMIA also suggested ONC adopt a “share first, structure later” data policy to keep important data elements from being trapped behind siloed systems.
Additionally, AMIA suggested ONC continue to seek feedback from stakeholders as the roadmap is implemented. The association also recommended the Recognized Coordinating Entity (RCE) hold public comment periods, listening sessions, and other meetings to ensure accountability and allow for active stakeholder involvement.
AMIA noted it will be several years before TEFCA provisions are operational across a majority of stakeholders, and said a more detailed timeline and implementation plan will help stakeholders better understand how TEFCA and US Core Data for Interoperability (USCDI) should work.
While implementing TEFCA will take time, AMIA believes the framework is ultimately tenable.
“While these goals are laudable, the details of these policies will require further refinement and significant time to be operationalized,” AMIA said. “Specifically, we anticipate that the TEFCA requirements to enable bulk transfer and individual access will require much more work to develop consensus on executable solutions.”
“Ultimately, these early networks will form the foundations for a learning health system,” AMIA continued.
To set the foundation for these early networks, AMIA stated individual access, bulk transfer, and consent management will require further refinement.
The HIMSS Electronic Health Record Association (EHRA) submitted its own 14-page comment letter to ONC primarily emphasizing a concern that the proposed framework does not build on current interoperability efforts, but instead suggests a drastic change to a singular architecture in a short period of time.
“We support the goal to provide nationwide interoperability using networks as important building blocks,” wrote EHRA. “However, as it stands, the proposed Trusted Exchange Framework suggests creation of new networks to become a QHIN rather than growing existing networks into QHINs.”
“We urge ONC to take the latter approach,” EHNAC continued.
Ultimately, EHRA identified 15 concerns and recommendations for necessary changes to the TEFCA draft. In an effort to ensure ONC sufficiently reviews all stakeholder feedback, EHRA recommended ONC publish an additional TEFCA proposed draft that offers more clarity about certain areas of the framework and allows for further stakeholder input.
Another of EHRA’s overall concerns is with TEFCA’s ambitious timeline and lack of specificity.
“As currently proposed by ONC, the TEFCA draft calls for aggressive timeframes for development and implementation of new standards without providing important details regarding testing mechanisms or clarity on how these new programs will be rolled out and coordinated with stakeholders,” the association stated.
EHRA also sought more information about how the additional costs associated with becoming a qualified health information network (QHIN) will be allocated, or how ONC plans to avoid de-incentivizing participation due to high costs.
Similar to AMIA, EHRA recommended the RCE collaborate with emerging QHINs and other stakeholders to establish a roadmap outlining how health data exchange will move from the current state to the new system.
“Such an approach allows for deploying architecture fit for purpose and adequate testing before widely deploying the agreed to capabilities,” stated EHRA.
More specifically, EHRA also voiced concern about reciprocity of data access and exchange, security mechanisms for network-to-network connections, patient matching, principles, responsibilities and definitions, and data storage by the QHIN, among other aspects of the framework.
The association offered recommendations for each area requesting modifications to TEFCA or further clarity about certain framework aspects.
“We believe the TEFCA has the potential to dramatically improve interoperability, however we recommend ONC look to leverage existing investments in interoperability and build upon these successes with close stakeholder collaboration,” concluded EHRA.