ONC Publishes TEFCA Details, FHIR Roadmap

With the Office of the National Coordinator for Health IT’s Jan. 18 publication of the Trusted Exchange Framework and Common Agreement (TEFCA), large health IT networks will soon be able to apply to become Qualified Health Information Networks (QHINs) as part of a nationwide data exchange. ONC also published a roadmap outlining how TEFCA will accelerate the adoption of FHIR-based exchange across the industry.

“Nationwide health information network exchange has been part of the ONC vision since our founding in 2004,” said Micky Tripathi, Ph.D., national coordinator for health information technology, in a briefing with reporters. “I think it also is part of everyone's sort of intuitive sense of interoperability,” but it is important that information is exchanged securely and reliably, he added. “That's what we're able to begin with the implementation phase of TEFCA today. It is through the consistent vision and dedication of many national coordinators, spanning many administrations, that we're now privileged to be able to bring that concept and intuition to reality today.”

Tripathi said ONC wants to strike the right balance between bringing more order to the market, but not so much order that it suppresses or is brittle to business and technical innovation. Individuals and providers ought to have a baseline expectation of being able to get basic health care, medical record information securely and reliably across the network, regardless of where they are, geographically, or which vendor or technology they're using, he added. “We also want to be able to greatly simplify connectivity.”

Mariann Yeager, CEO of the nonprofit Sequoia Project, which serves as the Recognized Coordinating Entity for TEFCA, said organizations will start applying to be QHINs in the second quarter of this year. Asked about the required capabilities of QHIN applicants, she said that there are expectations that any QHIN applicant must be able to respond to the exchange purposes of treatment and individual access services. “There will be additional parameters put around the other exchange purposes like payment, healthcare operations, public health, etc.,” she said.

Since participation in TEFCA is currently voluntary, Tripathi was asked if there was any planning around incentivizing participation. He said it is too early to talk about carrots or sticks related to TEFCA participation. “But we are working with federal agency partners about how they may have use cases that would benefit from being able to be TEFCA- enabled — with the CDC, for example, from a public health perspective, and with CMS for a wide variety of use cases. Those are active discussions, because we think there's a tremendous amount of benefit for the public at large and for making the federal government more efficient and more effective.”

The TEFCA HL7 FHIR Roadmap outlines how the use of the FHIR standard will become an established part of TEFCA-based exchange over time as the capabilities of the market mature. A revised QHIN Technical Framework (QTF) in 2023 will make network-facilitated FHIR-based exchange available as an option under TEFCA, while a planned revision to the QTF in 2024 would require FHIR.

The FHIR roadmap notes that the industry’s embrace of FHIR makes it imperative that TEFCA include a deliberate strategy to add FHIR-based exchange. Most FHIR implementation activity in the market has focused on point-to-point exchange of FHIR resources via FHIR APIs without network intermediaries, the roadmap notes. “However, some networks have leveraged their infrastructure to support FHIR in various ways. For example, a few nationwide and state/regional networks use existing IHE-based brokering infrastructure to exchange FHIR payloads. In addition, early pilot work has begun to use network infrastructure to support unbrokered, point-to-point FHIR API exchange. Finally, there are some networks that are planning to offer brokered FHIR API exchange.”

This roadmap envisions two paths for supporting FHIR exchange in TEFCA:
1) Facilitated FHIR exchange: QHINs provide network infrastructure support to facilitate unbrokered FHIR API-based exchange between Participants and Subparticipants from different QHINs.
2) Brokered FHIR exchange: QHINs broker FHIR payloads by routing FHIR APIs transactions between Participants and Subparticipants from different QHINs.

This roadmap notes that this approach provides continuity for the FHIR activities in the market today and allows TEFCA policy and technical infrastructure to accelerate FHIR adoption into the future. It also bridges network-based exchange communities and the emerging open API community, which have been operating in parallel up until now.

Yeager said the RCE will continue to seek input on the components of the Common Agreement as it puts them into practice, and operationalizes them with the first set of organizations that express interest in applying to become QHINs. “We do want to give stakeholders some time to unpack and understand what we've published,” she said, "so we'll be hosting a number of educational forums on that, and addressing a number of questions. Probably in about 90 days, we'll start accepting applications. We anticipate in the second quarter of 2022 that the initial set of applicants will come forward. We'll work with them through a defined process to verify that they do, in fact, meet the requirements and expectations for designating them as such. In 2022 and early 2023, we're going to work with that group on initial implementations.”