TEFCA QHIN-to-QHIN FHIR Exchange to be Piloted in 2025

Jan. 20, 2024
Updated Roadmap envisions four stages of development to allow TEFCA policy and technical infrastructure to accelerate FHIR adoption

The Sequoia Project, acting as the Recognized Coordinating Entity for the TEFCA interoperability framework, has released a revamped FHIR Roadmap for TEFCA Exchange that has a four-stage timeline for the gradual adoption of the FHIR (Fast Healthcare Interoperability Resources) standard for data exchange. 

Version 2 of the Roadmap envisions FHIR Exchange between Qualified Health Information Networks (QHINs), which is Stage 3 in the plan, to be piloted in 2025, with implementation specifications developed soon after the pilots are completed. This will enable QHINs to leverage FHIR for exchange between QHINs while continuing to support non-FHIR approaches within the QHINs’ internal networks.

The Office of the National Coordinator for Health Information Technology (ONC) has led a multi-year process alongside the RCE to implement TEFCA, which was envisioned by the 21st Century Cures Act. The idea is to create a “network of networks” for sharing health data across the country. The goal is that like wireless networks, electricity grids and ATMs, the user experience will become as if it's a single network.

In providing some background, the RCE noted that the initial work on TEFCA started with more established standards, such as IHE-based exchange of C-CDA content. But the rapid embrace of FHIR by the industry 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. However, some networks have leveraged their infrastructure to support FHIR in various ways,” the Roadmap document states. “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 FHIR API Exchange between endpoints and some networks are planning to offer brokered FHIR API exchange.”

The Roadmap envisions four stages of development to provide continuity for the FHIR activities in the market and allow TEFCA policy and technical infrastructure to accelerate FHIR adoption. “It also bridges network-based exchange communities and the users of FHIR APIs via ONC-certified EHRs and CMS required APIs, which have been operating in parallel up until now. We believe that both patterns of exchange will be important in the future and that use of FHIR APIs in TEFCA can help make these patterns complementary and finally deliver on the promise of a modern, digital healthcare system.”

The Roadmap shows four stages of FHIR exchange in TEFCA, with requirements for each stage built on the previous stage:

• Stage 1: FHIR Content Support
− Included as part of the initial launch of TEFCA.
− QHIN-brokered IHE exchange of FHIR payloads between QHINs available.
• Stage 2: QHIN-Facilitated FHIR Exchange
− QHIN support for facilitated FHIR API exchange required.
− Participant and Subparticipant exchange via FHIR APIs available.
• Stage 3: QHIN-to-QHIN FHIR Exchange
− Support for exchange between QHINs via FHIR APIs required.
• Stage 4: End-to-End FHIR Exchange
− Support for QHIN-brokered FHIR Exchange between Participants and

Each stage will be supported by a new version of the QHIN Technical Framework and managed via the change management process in the Common Agreement.

A timeline shows Stages 1 and 2 happening in 2024, with Stage 3 in 2026, and Stage 4 in an unspecified future time frame.

The RCE notes that Stage 4’s End-to-End FHIR Exchange would permit a Participant/Subparticipant to seamlessly exchange FHIR data between themselves and other network members through the QHINs and multiple other intermediaries both within a QHINs’ network and through the TEFCA-governed network. This requires further research into optimal methods for secure exchange through the network via the QHINs. When that research is complete, ONC will launch a pilot with TEFCA users to determine how and when that research can be rolled into a production environment.

The Common Agreement, released in September 2021, includes six exchange purposes that organizations must support to be designated as a QHIN. The exchange purposes include Treatment, Payment, Health Care Operations, Public Health, Benefits Determination, and Individual Access Services.

The following organizations were officially designated as the initial QHINS after successfully completing the TEFCA onboarding process.
• eHealth Exchange
• Epic Nexus
• Health Gorilla
• MedAllies

There are approximately 20 organizations formally seeking QHIN status. 


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