Health Affairs Article Points to HIO Readiness & Engagement in TEFCA

Vaishali Patel | June 22, 2021

The best way to gather information is by going straight to the source. That’s exactly what ONC did to learn and assess the state of health information entities, also known as health information exchange organizations (HIOs), across the country.  A recent survey conducted by Dr. Julia Adler-Milstein of University of California San Francisco (USCF), with ONC support, is the sixth national HIO survey of its kind. This instrument placed a particular emphasis on the proposed Trusted Exchange Framework and Common AgreementSM (TEFCASM). We reached out to 151 HIOs and asked questions designed to get a clearer picture of their state of affairs. (We included organizations supporting operational electronic HIE among independent entities.)  Some questions that we addressed included: what coverage do HIOs provide and who are their participants? What services do they provide and what barriers do they face? What is their level of interconnectedness with other HIOs? What are their current plans for participation in TEFCA?

We published these learnings and more in the latest issue of the journal Health Affairs.

Current State of HIOs

Health information organizations’ thoughts about TEFCA are core to building an interoperable network that enables HIOs and healthcare organizations to securely share electronic health information not only with each other, but with providers, individuals, and health plans.

At the time the survey was fielded—May, 2019 to February, 2020—a majority (56 percent) of HIOs said they plan to participate in TEFCA while 41 percent didn’t know if they would participate yet. Only 3 percent reported that they were not planning to participate in TEFCA.

A striking difference between HIOs that responded they were planning to participate compared to those that indicated they did not plan to do so was their existing level of connectedness and range of exchange capabilities. For HIOs planning to participate in TEFCA, 64 percent said they connect to health information exchanges (HIEs) in different states, and 90 percent said they participate in at least one national network. On the other hand, HIOs that did not plan to participate in TEFCA had lower levels of connectivity, with only 38 percent connecting to HIEs in different states, and 72 percent participating in at least one national network.

Leading indicators show that HIOs are in a good position to address any changes associated with the exchange landscape, including participating in TEFCA.  Although the number of operational HIOs has been in a steady decline since 2012, the financial viability of those remaining entities doubled (from 24 percent in 2012 to 52 percent in 2019). Additionally, many HIOs have a broad reach, based upon a number of different metrics, including: the number of participants, the number of providers that are either providing data or able to use the HIO, the different EHRs they are connected to, and in the work they do to facilitate exchange for a large number of patients.


These findings suggest a potential path for the future sustainability and growth of HIOs planning to participate in TEFCA. Survey results show that HIOs looking to participate in TEFCA are already building robust information-sharing networks — both state-to-state and nationally. This experience with network-to-network connectivity will be a strong advantage for HIOs as new opportunities arise under TEFCA—such as increased ability to offer data services—and could potentially make participating in TEFCA even more attractive to them.

The outlook is also positive for HIOs that are unsure whether or not they will participate in TEFCA. According to the survey results, HIOs that are uncertain about participating in TEFCA did not have major differences from the HIOs that are planning to participate. This means that under the right set of future conditions, (e.g., a viable set of benefits, low barriers to participation, and technical assistance) these HIOs will most likely take steps to improve their ability to connect to other networks.

Changes to HIOs Since 2014

Since our last survey in 2014, several upticks caught our interest; notably, we observed that concerns related to competition grew. For instance, from 2014 to 2019, the number of HIOs reporting competition from health IT vendors with HIE networks rose from 58 percent to 63 percent, and HIOs reporting competition from other HIE efforts rose from 35 percent to 42 percent.

At the same time, concerns related to technical infrastructure and standards notably decreased. The number of HIOs reporting barriers due to the limitations of current interface standards fell sharply from 68 percent down to 19 percent. The number of HIOs reporting technical barriers also fell dramatically from 59 percent to only 17 percent. Lastly, the number of HIOs who stated they lacked resources to implement interface standards fell as well, dropping from 63 percent to 22 percent.

An area for future growth for HIOs is related to the types of services they offer. Currently, the most prevalent general services they offer relate to exchange and management of patient-level data, while value-added services that go beyond those general services were offered less often. With TEFCA, HIOs will see greater opportunity to grow these services that leverage their exchange and data capabilities. This will represent a new opportunity—as well as a challenge—for HIOs as they move forward to build on their strengths within the regions and states they serve.

For more details on the survey results and information about HIOs and their participation in the upcoming TEFCA, read our recent article in Health Affairs.