Tefca First Qhins Designated

On 12 December 2023 the Office of the National Coordinator for Health IT and The Sequoia Project designated the first six Qualified Health Information Networks (QHINs) under the Trusted Exchange Framework and Common Agreement (TEFCA). Designated QHINs can now complete production testing and begin onboarding participants in 2024, creating a federally endorsed backbone for nationwide data exchange. This milestone represents over a decade of effort to establish interoperable health information exchange infrastructure across the United States, enabling patients, providers, payers, and public health agencies to access and share health information regardless of which systems originally captured that data.

TEFCA Framework Background

The 21st Century Cures Act directed ONC to develop a Trusted Exchange Framework and Common Agreement that would enable nationwide health information exchange through a network of networks approach. Rather than mandating a single national health information exchange, TEFCA establishes common rules that participating networks agree to follow, enabling data sharing across previously siloed regional and organizational boundaries.

The Sequoia Project serves as the Recognized Coordinating Entity (RCE) responsible for developing the Common Agreement, qualifying networks, and managing the TEFCA ecosystem. Years of stakeholder consultation, pilot testing, and framework refinement preceded the December 2023 QHIN designations.

Initial QHIN Designations

The six initial QHINs bring different capabilities, geographic strengths, and participant bases to the TEFCA ecosystem. Each QHIN operates as a hub connecting its participants to other QHINs and their participants through standardized exchange protocols.

QHIN capabilities include individual access services enabling patients to obtain their records, provider directory services supporting care coordination, and exchange messaging supporting clinical workflows. Geographic coverage varies, with some QHINs offering national reach while others bring regional strength and existing participant relationships. The diversity of initial QHINs provides options for organizations evaluating TEFCA participation while creating competitive pressure supporting service quality and innovation.

Participation Strategy Considerations

Evaluate which designated QHIN aligns with organizational geography, capabilities, and pricing for connecting to TEFCA exchange infrastructure. Selection criteria should include QHIN geographic coverage and participant base relevant to your patient population and referral patterns. Technical capabilities should align with your exchange needs including individual access services, query-based exchange, and public health reporting.

Pricing models vary across QHINs, requiring evaluation of connection fees, transaction charges, and support costs. Implementation support offerings differ, with some QHINs providing more full onboarding assistance. Organizations may eventually connect through multiple QHINs to improve coverage and capabilities, though initial setup typically focuses on a primary QHIN relationship.

Contract and Legal Readiness

Review common agreement terms, flow-down requirements, and privacy policies before signing participant agreements establishing TEFCA participation. The Common Agreement establishes baseline rules that all TEFCA participants must follow, with QHINs flowing down these requirements to their connected participants. Privacy policies must align with TEFCA minimum necessary, purpose of use, and patient consent requirements while remaining consistent with HIPAA and state privacy laws.

Business associate agreements address the relationships among participants, QHINs, and the RCE. Legal review should evaluate liability allocation, dispute resolution procedures, and termination provisions. If you are affected, understand their obligations before committing to participation.

Technical Implementation Planning

Assess network connectivity, FHIR roadmap commitments, and message orchestration services offered by each QHIN supporting technical integration. TEFCA exchange leverages emerging FHIR-based standards alongside established document exchange formats, requiring EHR and integration engine capabilities supporting both approaches. Network connectivity must meet performance and reliability requirements for production exchange.

Security requirements include certificate management, encryption standards, and audit logging capabilities. Testing procedures must show technical compliance before production activation. If you are affected, inventory their current interoperability capabilities and identify gaps requiring remediation before TEFCA onboarding.

Policy and Governance Alignment

Update information sharing policies, patient access statements, and breach notification procedures to meet TEFCA participation requirements. Governance structures should address TEFCA decision-making including participation scope, use case prioritization, and issue escalation. Compliance monitoring should track adherence to Common Agreement requirements and QHIN-specific obligations. Incident response procedures should address TEFCA-specific scenarios including exchange failures, privacy incidents, and data quality issues. Training programs should prepare staff for TEFCA workflows and compliance requirements.

Implementation Coordination

Map testing milestones, certificate management, and production cutover activities to align with QHIN onboarding schedules. Engage multi-state teams—clinical, payer, and public health—to coordinate TEFCA onboarding timelines. Integrate TEFCA readiness into interoperability steering committees alongside HTI-1 and CMS API programs. Establish dashboards for exchange volume, response times, and availability to monitor QHIN performance after production activation.