In this interview, Ken Leonczyk speaks with Casey Silverthorn, Orion Health’s State Health Data Center of Excellence Director, to break down the impact of the Trusted Exchange Framework and Common Agreement (TEFCA), the US nationwide framework for health information sharing. They discuss TEFCA’s potential to reshape data-sharing for providers, HIEs, and patients, covering both the challenges and the transformative possibilities. Whether you’re deeply involved in health data or new to TEFCA, Casey offers clear insights into what’s next for healthcare interoperability.
 

Ken Leonczyk: I’m excited to be here with Orion Health’s Director of the State Health Data Center of Excellence leader and all-around HIE and data expert, Casey Silverthorn. We’re going to have some real talk about TEFCA and its current impact on the health data exchanges, public health, and health care writ large.

I’m also going to dive into the potential impact of TEFCA on HIEs, Healthcare Providers (large and small), technology companies, and most importantly patients. So if you’re deep in TEFCA and been considering how it impacts your particular organization (HIE, Health System, Hospital, Provider organization, Technology company, Lab, Vendor, you name it), this interview should have some things for you to consider and if you’re new to the conversation, this is your one-stop shop to learn all about TEFCA.

But let’s start with a bit of level-setting. The ability to get the right data, actionable data to the right provider at the right setting at the right time is the mission of Orion Health, it’s a key priority of the US Healthcare system.

It’s also an area where we can and should do better in the US.

We need patients and clinicians to have better access to actionable data and to insights that come from data in order to improve care outcomes and to improve overall patient experience.

Ken: Casey, thanks for spending some time with me talking about this important and often misunderstood – and sometimes controversial—area of data sharing. Let’s get started with the basics. What is TEFCA?

Casey Silverthorn: TEFCA is the Trusted Exchange Framework and Common Agreement. It encompasses both technical aspects as well as governance. It provides common sharing language amongst the participants and sub participants of the QHINs, as well as a common standard set of transactions that will be utilized to exchange data.

Ken: So how “real” is this? Is this a sure thing or just a proposal? Or is this something that is “real”, but jury is out on its impact?

Casey: As of right now it is somewhat in the middle ground. TEFCA is a real thing in the fact that the QHINs have been named and the rules of the road have been articulated. However, there is not a penalty to organizations not being part of a QHIN. Also, the technical SOP continues to evolve. TEFCA is real, but the details are still being ironed out.

Ken: So, there’s no teeth yet but there’s a lot of attention. What was the purpose of TEFCA? Why did it come? What problem was it supposed to solve?

Casey: My personal belief is that this further expands on the work the eHealth Exchange has done with the national network approach in the past. They acted as the hub connecting CareEquality and Commonwell into a seamless national exchange and TEFCA expands the use cases and adds some clarity to the rules

Ken: Do you think it’ll solve that problem?

Casey: No. TEFCA is introducing other organizations into the conversation that might not have aligned values and like a standard, each organization will have their own technical flavor of doing things. I think TEFCA in its current form will confuse and distract organizations from other good work they might be doing.

Ken: So how does it all work? Describe how everything is supposed to work together? Let us know about QHINs and other entities as well as the framework and logistics laid out by TEFCA.

Casey: A QHIN is a Qualified Health Information Network and will act as one of the hubs in the exchanging of information nationally.  Various healthcare organizations or HIEs would connect to a QHIN and therefore have the ability to exchange with any other organization connected to a QHIN.

The QHINs would exchange data with each other based on which endpoints/sources/facilities are connected to each QHIN. The Common Agreement piece within TEFCA is key to this level of national exchange being achievable. The Common Agreement standardizes sharing agreements amongst all participants within TEFCA to allow the same level and type of sharing.

In theory, if a provider is seeing a new patient, they could query the national exchange under TEFCA and get information on that patient from anywhere in the country. I personally think asking a doctor to go retrieve data and then sift through what they get back will be a barrier to this being widely used. From the EMR perspective, merging information into a patients record from an outside source usually requires a human to review the information prior to merging into the system. Maybe its just me being negative about this, but I don’t see how TEFCA is going to move the needle on making America healthier and the money could be put toward better initiatives.

Ken: What happens when the administration changes, does TEFCA end?

Casey: Personally, I think we are too far down the road for it to just disappear. I think a change in administration could change what it ends up being or delay the finalization of the technical SOP, but I think some flavor of TEFCA will remain, even if it is called something else.

Ken: Let’s stay in the political realm for a moment – What do you think, does Trump like TEFCA?

Casey: I am not sure whether Trump himself likes TEFCA or not. But if Trump were to be re-elected, he would have the ability to bring in his own cabinet which could change the direction and focus of the government bodies in charge of TEFCA. 

Ken: How about Kamala Harris?

Casey: Same answer as Trump, I am not sure where the candidates stand on TEFCA in particular. But with both candidates, we would be looking at shake ups within the federal hierarchy.

Ken: Ok, so what organizations like TEFCA and why? What are some of the reasons why some aren’t that thrilled with it? Give us the low down on supporters and, if not detractors, questioners.

Casey: To be honest, I think a lot of the people in the health IT industry who have been working on interoperability for a long time kind of roll their eyes a bit. We have heard CCDs were going to solve all our problems, the national networks helped in some regard, now it is FHIR. Some of these are just technologies and TEFCA is much more than that, but it feels like another initiative promising to change the interoperability landscape. And then of course, you have the HIEs that might feel as if this is eroding the value they provide to their participants and might put their sustainability in jeopardy in some cases.

Ken: I’ve been reading a lot about vendors and their role in TEFCA. And I’ve heard some rumblings from State and regional HIEs about QHINS and Epic. So, I’m wondering, how can Epic be a QHIN?

Casey: This is an interesting question. Traditionally we have always thought of national exchange networks as non-profit entities that can act as a neutral 3rd party between government and healthcare. Epic and other for-profit organizations clearly have their own financial incentives for being QHINs. In the past, the neutral non-profit exchanges could connect any EMR that could support the technical requirements for exchange. Can a non-Epic customer connect to Epic QHIN? Is Epic taking advantage of their saturation in the market to make more money off of TEFCA with existing clients? Dare I say monopolistic behaviors? Something about it feels wrong, but we will see how Epic plays nice with others as TEFCA unfolds.

Ken: Now for a blunt question for you — Is TEFCA the end of local and state HIEs?

Casey: I certainly don’t think so, although some of the QHINs might think that with TEFCA the HIEs become irrelevant. There are many, many use cases that can’t simply be solved with query and retrieve type of exchange. Also, the small healthcare organizations are the ones that are most affected and will more than likely need an HIE to help them adhere to TEFCA requirements

Ken: I’m glad to hear that. HIEs are too important a part of the healthcare ecosystems to get written out of existence. I also see so much potential for HIEs to grow and offer such an important service to our communities. So, let me ask, how can HIE’s participate in TEFCA?

Casey: HIEs need to sign up with a QHIN and establish the connectivity between the HIE platform and the QHIN. This is probably the easy part. The hard part is having flow down governance language added every participation agreement or an amendment to each participation agreement. Many years ago, we witnessed the challenge with this as HIEs were signing the DURSA with the eHealth Exchange.

Ken: So, what do you think about the future and the role of our company, Orion Health? How can Orion help HIEs and other organizations with TEFCA?

Casey: We can support by providing expertise around TEFCA with lessons learned from our various clients. We also provide technology that allows our clients to have the freedom to choose their QHIN of choice and support them on their TEFCA journey.

Ken: How do you think TEFCA will impact other provider organizations like hospitals, labs, medical groups, and so on?

Casey: For the hospital and large health systems, we could see them pull out of their HIEs and just join the Epic QHIN. I think this could end up being a barrier for access to information, especially in the short term. For labs and medical groups, I think some of their challenges will be on the technical front and finding a vendor that can even support being a part of a QHIN. A lot of the EMR vendors that support those types of facilities don’t have super mature interoperability offerings.

Ken: Ok, Casey, a penultimate question for you. What do you see as the biggest opportunity for HIEs, health systems, and provider organizations given the changes in data sharing and interoperability that we’re seeing and will continue to see due to TEFCA?

Casey: For HIE, the opportunity is to innovate and be better. Some have been better than others at doing this already. For the health systems and provider organizations, the opportunity is understanding the TEFCA sharing language and then thinking outside the box on forming an interop strategy. The organizations with good leadership that understand the healthcare ecosystems in which they operate and strive to provide excellent care will rise to the top.

Ken: So, Casey, we’ve talked about the impact of TEFCA on most of the healthcare ecosystem, except for the most important group, patients! What do you think the impact of TEFCA on patients will be?

Casey: I think TEFCA has the opportunity to change the level of care they receive, although it will take awhile to get there. Remember, TEFCA brings the governance and framework for exchange and it will still be up to the individual organizations to truly enable exchange and move the needle for the patients. I believe we will make a difference, but the industry will need to get past the governance and paperwork part first before the patients will start to feel an impact.

Ken: Ok, final question. What do you think an HIE’s top priority should be to ensure they’re serving the needs of our patients in this new post-TEFCA environment?

Casey: I think the HIEs just need to be prepared regardless of where TEFCA goes. Having a technical plan in place for joining a QHIN as well as the governance piece with their participants ready will allows the HIEs to act quick if they have not already.