Trusted Exchange Framework and Common Agreement: A Common Sense Approach to Achieving Health Information Interoperability

Genevieve Morris | January 5, 2018

The 21st Century Cures Act (Cures Act), signed into law in December 2016, calls on the Office of the National Coordinator (ONC) to work with federal partners, including the National Institute of Standards and Technology (NIST), and the healthcare and health information technology (health IT) industries to provide interoperability for all.

Currently, there are many Health Information Networks (HINs) that operate locally, regionally, or nationally.  But often, these entities don’t exchange health information with each other due to variations in their participation agreements and sometimes competitive interests. This limits the ability of individuals, providers, health systems, public health, and others to use the existing HINs to exchange data no matter where an individual has received care. Building and maintaining trust across and among these HINs is key to interoperability of health information outlined in the Cures Act. This affects everyone in the country – patients and their family members, providers, public health officials, and health plans and systems that need information to ultimately help improve patient care and outcomes.

By releasing the draft Trusted Exchange Framework for public comment, ONC is one step closer to fulfilling the Cures Act’s requirement to “develop or support a trusted exchange framework, including a common agreement among health information networks nationally.”

But we know we can’t do this alone. In fact, the law calls on ONC to bring together our stakeholders and solicit feedback from them on their experiences in building trust and exchanging health information. Throughout this year we’ve done exactly that. The proposed Trusted Exchange Framework reflects what we heard from three wide-reaching listening sessions and the input we received during a 60-day public comment period over the summer, along with many ongoing conversations we have had directly with stakeholders.

Based on the information we received, the proposed Trusted Exchange Framework establishes five overarching goals outlined in the Glide Path we also issued today that will help in the national efforts to bring about an interoperable healthcare system:

Goal 1: Build on and extend existing work done by the industry

Goal 2: Provide a single “on-ramp” to interoperability for all

Goal 3: Be scalable to support the entire nation

Goal 4: Build a competitive market allowing all to compete on information services

Goal 5: Achieve long-term sustainability

The proposed Trusted Exchange Framework is divided into two parts.  Part A-Principles for the Trusted Exchange Framework provides general principles designed to provide guardrails and promote trust between Health Information Networks based on the current state of existing trusted exchange frameworks. Part B-Minimum Required Terms and Conditions, operationalizes the principles in Part A by creating a well-defined path to create the single on-ramp we seek to achieve. Specifically, Part B identifies a set of minimum terms and conditions to help ensure that common practices are in place and required of all participants.

The draft Trusted Exchange Framework focuses on policies, procedures, and technical standards that reflect the capabilities of existing health information networks, while also expanding interoperability capabilities.  Because ONC cannot do this alone, operationalizing the Trusted Exchange Framework will include the open and competitive selection of a single Recognized Coordinating Entity (RCE) from the industry and supported by ONC. Working collaboratively with ONC through a Cooperative Agreement, the RCE will use the Trusted Exchange Framework policies, procedures, technical standards, principles, and goals to develop a single Common Agreement that Qualified Health Information Networks (Qualified HINs) and their participants can voluntarily adopt. Once this has been accomplished, the Trusted Exchange Framework and Common Agreement (TEFCA) will be published in the Federal Register.

While much of the Trusted Exchange Framework is based on existing capabilities in the health IT landscape some modifications to existing HINs and Qualified HINs may be needed to meet the objectives identified by Congress in the Cures Act. These updates are designed to achieve the single on-ramp and to significantly reduce the need for multiple point-to-point interfaces, like those currently being used.  As stakeholders noted during the public comment period, these interfaces are costly, complex to create and maintain, and an inefficient use of provider and health IT developer resources.

The proposed Trusted Exchange Framework also supports ONC’s interoperability goals:

  1. Patients must be able to access their health information electronically without any special effort;
  2. Providers and payer organizations accountable for managing benefits can receive population level health information allowing them to analyze population health trends, outcomes, and costs; identify at-risk populations; and track progress on quality improvement initiatives; and
  3. The health IT community should have open and accessible application programming interfaces (APIs) to encourage entrepreneurial, user-focused innovation to make health information more accessible and to improve electronic health record (EHR) usability.

In addition to the draft Trusted Exchange Framework, ONC released a User’s Guide to Understanding the Trusted Exchange Framework and the US Core Data for Interoperability (USCDI) Glide Path to identify a roadmap for broadening the data that can be exchanged via the TEFCA.

We appreciate the insight, expertise, and input we received during the public comment period and encourage you to provide us with your comments on the proposed Trusted Exchange Framework before the comment period ends on February 20, 2018. [The deadline was extended until February 20, 2018 as the original deadline ended on a weekend.]