Moving Beyond Closed Networks – An Update on Trusted Exchange of Health Information

Don Rucker M.D. National Coordinator for Health Information Technology | April 19, 2019

In the 1990s, many Americans interacted with the Internet through America Online. While this platform was revolutionary, providing users with e-mail services and access to content, it was also a closed network. Their users were restricted from accessing applications, content, and services available outside of AOL’s approved content providers. In the healthcare landscape, we still have a similar dynamic today. Both national networks and local or regional health information exchanges provide valuable services to their users; however, these networks are often not connected and offer varied services and use cases. To address this issue, Congress included a provision within the 21st Century Cures Act to advance a Trusted Exchange Framework and Common Agreement (TEFCA) to improve data sharing between health information networks.

Trusted Exchange Framework and Common Agreement Update

Today the Department of Health and Human Services took another step towards advancing the access, exchange, and use of health information by issuing three documents for public comment that would support network-to-network exchange of health information nationally. Collectively, these documents seek to provide a single “on-ramp” to nationwide connectivity, while advancing a landscape where electronic health information securely follows the patient and can be queried, retrieved, and delivered when and where it is needed. These documents include:

  • Second drafts of the (1) Trusted Exchange Framework (TEF) and the (2) Minimum Required Terms and Conditions (MRTCs), which were previously in one document; and
  • A first draft of the Qualified Health Information Network (QHIN) Technical Framework, which describes technical and functional requirements to implement the Common Agreement and enable health information networks to connect to each other.

The challenge before us – for ONC and the broader community – is to work as efficiently as we can to advance towards nationwide interoperability, which will inject competition and transparency into healthcare to empower patients and drive down costs.

Collectively, these documents will form the basis of a single Common Agreement that will create baseline technical and legal requirements for sharing electronic health information on a nationwide scale. Through the Common Agreement, electronic health information sharing can occur across disparate health information networks to the benefit of improved care for the patient.

I am also pleased to announce that we are issuing a Notice of Funding Opportunity for a Recognized Coordinating Entity (RCE) to develop, update, implement, and maintain the Common Agreement and the QHIN Technical Framework.

We are incredibly grateful for the public’s interest and feedback on Draft 1 of TEF. We received more than 200 comments on the first draft, the majority of which were supportive of its goals and direction. Our team carefully reviewed all of the comments to ensure we understood stakeholder concerns and suggestions. Additionally, the Health Information Technology Advisory Committee provided a set of 26 recommendations. Nationwide interoperability is not a simple undertaking, and something as expansive as a final TEFCA requires thoughtful consideration of the issues and challenges. For example, a successful “network of networks” requires that each network that facilitates connectivity agrees to the same mix of technical standards, policies, and legal conditions. By releasing today’s draft for a second round of public comment, we are working to get it right.

The following are some common themes we heard from the first round of public comment along with key updates.

Wide support for a Recognized Coordinating Entity (RCE)

In the first draft of the TEF, we indicated our intention to use a funding announcement to work with an outside organization to operationalize a final Common Agreement. ONC will work with the selected RCE to incorporate the TEF into a single Common Agreement to which QHINs voluntarily agree to adhere. While there were questions and varying opinions regarding the distribution of work and authority between the ONC and an RCE, the majority of stakeholders supported our plan to select an RCE. The Cooperative Agreement for the RCE will be a four-year award and will include requirements for the RCE to demonstrate a commitment to transparent, fair, and nondiscriminatory data exchange through organizational policies and governing structures.

Specification of Standards

We included a number of privacy, security, and technical standards in the first draft of the TEF. Many commenters indicated that the Common Agreement would not be the best place to specify all of the standards, which may need to be updated more frequently than a legal agreement. Commenters suggested specifying standards through implementation guides, rather than in the Common Agreement itself. Thus in the second draft, we included most standards requirements in the draft QHIN Technical Framework, which will be incorporated into the Common Agreement by reference, and with appropriate notice and compliance provisions for implementation of any updated technical requirements.

Qualified Health Information Networks Definition Broadened

In the first draft of the TEF, we defined a new type of organization – the QHIN. Our goals are to help advance a fair and equitable market and support successful QHINs that can support scalable interoperability. In response to comments that the definition of QHIN was too restrictive, we expanded the definition to allow for more types of stakeholders to apply. We also updated the application process to allow for a provisional period where QHINs will onboard to the Common Agreement and undergo testing and surveillance to ensure they are in compliance before actively exchanging data on the network.

Inclusion of Push Transactions

We received a number of requests from commenters asking that we include a push-based exchange modality in the Common Agreement. Commenters noted that push transactions play a vital role in supporting transitions of care and public health use cases and would be necessary to fully support required public health reporting. Therefore, ONC has included QHIN Message Delivery, which supports instances in which a QHIN sends electronic health information to one or more QHINs for delivery. We believe the value of push transactions is significant to deliver critical information about patient care.

Next Steps in Implementing TEFCA

We sincerely appreciate the thoughtful feedback we received during the first round of public comment. The challenge before us – for ONC and the broader community – is to work as efficiently as we can to advance towards nationwide interoperability, which will inject competition and transparency into healthcare to empower patients and drive down costs. We are committed to advancing a TEFCA that helps achieve these goals. Please review the new documents and provide your comments by June 17, 2019.