What Is TEFCA and Why Does It Matter for Healthcare?

| Author , tagged in Healthcare, tefca
Cloudticity, L.L.C.

Over the past two decades, healthcare organizations have ramped up adoption of new information technology (IT) solutions as part of their efforts to improve operational efficiencies and deliver better healthcare outcomes. These solutions have the potential for enabling providers to securely share electronic health information (EHI) among clinical teams, allowing payers to identify key trends among large patient populations, empowering patients to take control of their own health information, and more.

Unfortunately, while adoption of new technologies has been strong, interoperability among solutions remains a significant challenge. Many providers, payers, patients, and health information networks (HINs) have been unable to realize the full promise of healthcare IT because they have difficulty exchanging healthcare information among disparate, proprietary systems.

The U.S. Office of the National Coordinator for Health Information Technology (ONC) is helping address this challenge of exchanging healthcare information through the Trusted Exchange Framework and Common Agreement (TEFCA). By defining standard principles and practices, ONC hopes to establish trust among healthcare organizations and enable the exchange of information among those organizations across the United States.

In this blog post, we’ll highlight what your healthcare organization needs to know about TEFCA and why TEFCA is important for healthcare industry participants.

What is TEFCA?

TEFCA is a framework that creates the technical and legal infrastructure for sharing EHI among healthcare organizations across the United States. It was developed to support provisions within the 21st Century Cures Act, which mandated improvements in the secure exchange of health information between networks, and the Cures Act Final Rule, which defined interoperability requirements. Providers, patients, payers, state agencies, public health professionals, and other organizations can all use TEFCA by adopting its policies, technical specifications, and requirements.

TEFCA has two primary components:

  • The TEF (Trusted Exchange Framework) includes non-binding principles to help establish trust and facilitate the exchange of information among HINs. ONC maintains the TEF.
  • The CA (Common Agreement) defines an infrastructure model and governing approach for securely sharing basic clinical information among networks. ONC works with an industry-based Recognized Coordinating Entity (RCE) to develop, update, implement, and maintain the CA.

There are several ways to participate in TEFCA. A HIN can apply to become a Qualified Health Information Network (QHIN), which connects directly with other QHINs to exchange information. ONC has created requirements for QHINs, and beginning in 2022, organizations will be able to apply to the RCE to become QHINs.

Other organizations—such as health systems, health tech businesses, payers, federal agencies, or HINs—can be TEFCA “participants” if they contract with QHINs. “Subparticipants” are people or organizations that use the services of a participant to send and receive EHI. Those subparticipants might include health systems, ambulatory providers, health tech businesses, or payers. Individual users—such as patients, health plan members, and patient representatives—can also access information that is shared by QHINs, participants, and subparticipants.

Why is TEFCA important?

By helping streamline the secure exchange of health information, TEFCA can deliver important benefits to healthcare organizations and patients.


Better exchange of healthcare information can help individuals who need medical assistance while they are traveling across their state or when they are moving across the country. When providers have up-to-date healthcare information readily available, patients can avoid reiterating their entire medical history and submitting to duplicative tests. Patients can also gain easier access to their own healthcare information, which will help them take greater control of their own care.


With faster, more efficient access to patients’ health information, providers will be able to improve clinical decision making. They can also better coordinate care among specialists and facilities.


TEFCA can help payers gain a more complete view of their members’ healthcare interactions. That visibility can in turn simplify authorization for services and enable payers to identify candidates for case management assistance. With better access to health data, payers can also support value-based payment models and better identify trends among patient populations.


HINs will be able to enhance the value of their services by giving providers easier access to information that was collected outside of their network. At the same time, HINs can more easily share information to outside organizations, from public health agencies to post-acute care facilities. And because TEFCA can help reduce the complexity of exchanging information, HINs can focus on creating new, innovative value-added services.

Health tech businesses

Improving interoperability and facilitating easier exchange of healthcare information among organizations will open new opportunities for innovation. Health tech businesses can create new apps and services that enable providers, payers, and patients to do more with that vital information.

Of course, for healthcare organizations to benefit from TEFCA, they will need to understand how its components will affect their IT environment and operations. For example, providers will need to know how to connect to a QHIN and how their choice of data storage (such as the use of cloud storage) might affect how data is shared. In many cases, working with an external service provider that has TEFCA expertise will be the most efficient way to capitalize on TEFCA.

What has changed from the initial TEFCA draft?

After previous drafts in 2018 and 2019, the TEF was officially published in January 2022 along with the CA. Over the course of drafting and revising the TEF, ONC made a number of changes. For example, between drafts 1 and 2, ONC:

  • Broadened the definition of a QHIN: The new definition enables more HINs to apply.
  • Updated exchange “purposes”: ONC expanded the list of ways that organizations might use a trusted exchange. Those purposes range from treatment, benefits determination, individual access services, and public health support to quality assessment and improvement, business planning and development, and utilization review.
  • Drafted a QHIN Technical Framework: This framework addresses the technical requirements for exchanging information among QHINs.
  • Added message delivery push: With this change, organizations can send a patient’s EHI to a specific QHIN for delivery.

After draft 2 of the TEF, ONC made additional changes to that document, associated documents, and the overall program. For example:

    • Named the RCE: In 2019, ONC awarded a cooperative agreement to The Sequoia Project to be the RCE that would administer the CA and govern network-to-network connections by HINs.
    • Revised the principles: In the TEF, ONC added a principle about equity: HINs should consider the effects of interoperability on different populations. ONC also refined the principle about the public health purpose.
  • Published CA version 1.0: ONC and the RCE published the first version of the Common Agreement (CA) for Nationwide Health Information Interoperability.
  • Moved elements to the CA: ONC moved the Minimum Required Terms and Conditions and the Additional Required Terms and Conditions from the TEF to the CA.

Published QHIN Technical Framework version 1.0: This framework describes the functional and technical requirements that a HIN must fulfill to serve as a QHIN under the CA.

How does TEFCA affect FHIR?

The Fast Healthcare Interoperability Resources (FHIR) specification—created by not-for-profit Health Level Seven International (HL7)—was designed to enable the exchange of EHI. Healthcare organizations have begun implementing FHIR, but as ONC noted, FHIR has not yet been adopted widely for exchanging information in multi-networked environments.

As a result, The Sequoia Project has published the FHIR Roadmap for TEFCA Exchange. This three-year roadmap was created to help align and drive FHIR adoption across the industry.

(Learn how your organization can speed adoption of this standard with FHIR Works on AWS and the Cloudticity Oxygen™ managed cloud solution.)

Start benefiting from TEFCA

By enhancing interoperability and streamlining the exchange of EHI, TEFCA can benefit not only patients but also providers, payers, HINs, and other healthcare organizations. But for these organizations, making the most of TEFCA will require some planning. Working with a partner that has deep expertise in healthcare technology can accelerate your journey.

Learn how Cloudticity can help your organization make the most of TEFCA. Contact us today.


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