Technical Guide to TEFCA | Medplum

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Andrei Zudin is a healthcare interoperability expert and advisor to the Medplum community. He is the former CTO and co-founder of Health Gorilla.

A Technical Guide to TEFCA Integration for Software Developers and Health IT Professionals ( Download as PDF)

Purpose [​](/content/blog/technical-guide-to-tefca#purpose "Direct link to Purpose"/index.html)

This white paper aims to provide a technical guide for software developers and healthcare IT professionals seeking to integrate their systems with the Trusted Exchange Framework and Common Agreement (TEFCA). It delves into the technical aspects of TEFCA, including the various participation models, QHIN connectivity, data exchange methods, and security considerations. It also explores the incentives for TEFCA participation and how Medplum can help organizations achieve TEFCA compliance and leverage its benefits.

Background [​](/content/blog/technical-guide-to-tefca#background "Direct link to Background"/index.html)

The healthcare industry has long struggled with fragmented data, leading to inefficiencies, errors, and suboptimal patient care. TEFCA represents a step towards addressing these challenges by establishing a nationwide framework for secure and interoperable health information exchange1. By participating in TEFCA, healthcare organizations can improve care coordination, reduce costs, and enhance patient outcomes2.

Understanding the TEFCA Framework [​](/content/blog/technical-guide-to-tefca#understanding-the-tefca-framework "Direct link to Understanding the TEFCA Framework"/index.html)

TEFCA, enacted through the 21st Century Cures Act, aims to establish a universal policy and technical floor for nationwide interoperability3. It seeks to simplify connectivity for organizations to securely exchange information to improve patient care, enhance the welfare of populations, and generate healthcare value3. TEFCA operates as a "network of networks," connecting various Health Information Networks (HINs) across the country1. These HINs, upon meeting specific criteria and undergoing a vetting process, are designated as Qualified Health Information Networks (QHINs)4.

TEFCA Goals [​](/content/blog/technical-guide-to-tefca#tefca-goals "Direct link to TEFCA Goals"/index.html)

TEFCA has three primary goals:

1. Establish a universal policy and technical framework for nationwide interoperability.
2. Simplify connectivity for organizations to securely exchange information.
3. Empower individuals (patients) to gather their own health information3.

Trusted Exchange Framework (TEF) Principles ​

The Trusted Exchange Framework (TEF) outlines seven foundational principles for trust policies and practices to facilitate data sharing among HINs:

1. Standardization: Prioritize the use of federally recognized and industry-acknowledged technical standards, policies, best practices, and procedures for a cohesive and efficient exchange ecosystem5.
2. Openness and Transparency: QHINs should operate transparently, promoting stakeholder trust and fostering a collaborative environment5.
3. Cooperation and Non-discrimination: QHINs should cooperate with each other and not discriminate against other HINs or participants5.
4. Privacy: QHINs should prioritize the privacy of individuals' health information and comply with applicable privacy laws and regulations5.
5. Security and Safety: QHINs should ensure the security and safety of health information exchange, protecting it from unauthorized access and disclosure5.
6. Access: QHINs should facilitate and promote a clear understanding of how information has been used or disclosed while adhering to civil rights obligations on accessibility5.
7. Equity: QHINs should consider the diverse impacts of interoperability on different populations and throughout the entire lifecycle of the activity, ensuring an inclusive approach5.

These principles guide the development and implementation of TEFCA, fostering a trustworthy and reliable health information exchange ecosystem.

TEFCA Architecture [​](/content/blog/technical-guide-to-tefca#tefca-architecture "Direct link to TEFCA Architecture"/index.html)

TEFCA operates as a " network of networks," connecting various Health Information Networks (HINs) across the country1. These HINs, upon meeting specific criteria and undergoing a rigorous vetting process, are designated as Qualified Health Information Networks (QHINs)4. QHINs serve as facilitators of nationwide interoperability within the TEFCA framework, adhering to a common set of rules and technical specifications1.

Participants, such as healthcare providers, health systems, payers, connect to a QHIN to engage in TEFCA exchange6. Subparticipants, often members of a Participant's organization, can also connect to a QHIN through a Participant6. This layered structure creates an interconnected network where data can flow seamlessly between different organizations and systems.

The following table illustrates the different ways an organization can participate in TEFCA:

Qualified Health Information Networks (QHINs) ​

QHINs are the foundation of the TEFCA framework, responsible for ensuring secure and reliable health information exchange across the network1. They play a crucial role in upholding the principles of TEFCA and ensuring compliance with the Common Agreement.

To become a QHIN, an organization must meet stringent requirements, including:

• Ownership Requirements: Being a U.S. entity with no foreign control that could pose a national security risk7.
• Exchange Requirements: Demonstrating the capability to exchange Electronic Health Information (EHI) with multiple unaffiliated organizations, supporting all required exchange purposes, and adhering to non-discrimination policies7.
• Designated Network Services Requirements: Maintaining a robust and secure network infrastructure, establishing data governance policies, and ensuring compliance with privacy and security standards8.

QHIN Onboarding

The QHIN onboarding process involves several steps to ensure the organization's readiness for participation in TEFCA exchange. This includes:

• Application and Review: Submitting a comprehensive application with supporting documentation and undergoing a thorough review by the Recognized Coordinating Entity (RCE)7.
• Testing: Conducting tests to ensure the QHIN's network can connect to those of other QHINs7.
• Production Environment Integration: Successfully integrating the QHIN's network into the TEFCA production environment and demonstrating the ability to exchange data with other QHINs7.

This rigorous onboarding process ensures that QHINs meet the technical and operational requirements for secure and reliable health information exchange within the TEFCA framework.

As of March 2025, eight organizations have been designated as QHINs:

Data Exchange Methods [​](/content/blog/technical-guide-to-tefca#data-exchange-methods "Direct link to Data Exchange Methods"/index.html)

TEFCA supports both document-based (CDA) and FHIR-based exchange methods to accommodate the diverse needs of healthcare organizations.

Document-Based Exchange

The initial iteration of TEFCA focuses on document-based exchange, leveraging existing standards and infrastructure9. This involves the exchange of HL7 CDA documents, which are widely used in healthcare for sharing clinical information9. TEFCA leverages Integrating the Healthcare Enterprise (IHE) profiles, such as Cross-Community Patient Discovery (XCPD) and Cross-Community Access (XCA), to facilitate the secure retrieval of these documents5.

FHIR-Based Exchange

While the first iteration of TEFCA focuses on document-based exchange and supports facilitated FHIR exchange, FHIR is not mandatory at this time. Nevertheless a large number of Participants and Sub-participants voluntarily use FHIR as it addresses their needs best. Examples of such use cases included but not limited to Individual Access Services using SMART-on-FHIR and Electronic Case Reporting. More use cases and exchange purposes are on the roadmap for future development9. The TEFCA FHIR roadmap outlines a phased approach for incorporating FHIR into TEFCA, with the goal of enabling more granular and standardized data exchange5. This will allow developers to leverage FHIR APIs for accessing and exchanging data, promoting interoperability and innovation in healthcare applications.

Patient Matching in TEFCA [​](/content/blog/technical-guide-to-tefca#patient-matching-in-tefca "Direct link to Patient Matching in TEFCA"/index.html)

Patient matching is a critical aspect of TEFCA, ensuring that the correct patient data is accessed and exchanged5. Accurate patient matching is essential for preventing errors, improving care coordination, and ensuring the integrity of health information exchange.

TEFCA acknowledges the challenges of patient matching and plans to work with QHINs to create future patient-matching guidelines5. This collaborative approach will help improve patient matching accuracy and consistency across the TEFCA network.

Key Considerations for QHIN Connectivity [​](/content/blog/technical-guide-to-tefca#key-considerations-for-qhin-connectivity "Direct link to Key Considerations for QHIN Connectivity"/index.html)

Connecting to a QHIN is a crucial step for organizations seeking to participate in TEFCA exchange. Here are some key considerations:

• Technical Requirements: Organizations must ensure their systems meet the technical specifications specific to the QHIN of their choice. Organizations can join several QHINs if necessary. Depending on the selected QHIN connectivity specifications may include supporting IHE profiles, FHIR IGs, security standards, patient matching methods, and provenance tracking6.
• Data Governance and Compliance: Organizations must establish data governance policies and procedures that align with TEFCA requirements and flow down agreements. This includes addressing data quality control, data storage, and legal considerations related to privacy and security10.
• Operational Considerations: Organizations should consider operational factors such as network traffic, potential data quality issues, and the dispute resolution process when connecting to a QHIN7.
• Choosing a QHIN: Organizations should carefully evaluate different QHINs based on their technical capabilities, network reach, governance model, and participation costs6.

Medplum & TEFCA [​](/content/blog/technical-guide-to-tefca#medplum--tefca "Direct link to Medplum & TEFCA"/index.html)

Becoming a TEFCA compatible FHIR responding node is part of the Medplum roadmap and we hope to connect with organizations that are interested in this functionality.

Today, Medplum is a healthcare platform that can help organizations achieve TEFCA compliance and leverage its benefits11. It offers a range of capabilities that align with TEFCA requirements, including:

• Integration Engine: Medplum's integration engine supports various healthcare data exchange standards, including FHIR, HL7, and CCD-A12. This allows organizations to connect their existing systems to QHINs and participate in TEFCA exchange.
• FHIR Support: Medplum is FHIR-native, providing a FHIR datastore and API for storing and accessing healthcare data13. This ensures compliance with TEFCA's future direction towards FHIR-based exchange.
• Security Features: Medplum prioritizes security and compliance, offering HIPAA compliance, SOC2 certification, and robust security controls14. This helps organizations meet TEFCA's security requirements and protect patient data.

The following are specific features that relate to TEFCA that are on the Medplum roadmap.

Addressing the Gaps [​](/content/blog/technical-guide-to-tefca#addressing-the-gaps "Direct link to Addressing the Gaps"/index.html)

Medplum is committed to supporting TEFCA and has a roadmap for addressing any potential gaps in its capabilities15. This includes plans for enhancing FHIR-based exchange functionalities, expanding its integration engine to support emerging TEFCA use cases, and continuously improving its security and compliance posture.

Medplum's Value Proposition [​](/content/blog/technical-guide-to-tefca#medplums-value-proposition "Direct link to Medplum's Value Proposition"/index.html)

Medplum offers a compelling value proposition for organizations looking to participate in TEFCA:

• Open-Source: Medplum's core technology is open source, providing flexibility, transparency, and community-driven innovation16.
• Comprehensive Feature Set: Medplum offers a wide range of features, including questionnaires, scheduling, communications, care plans, and analytics, enabling organizations to build comprehensive healthcare solutions16.
• Simplified Compliance: Medplum simplifies compliance with HIPAA and other healthcare regulations, providing built-in audit capabilities and secure authentication16.

Incentives for TEFCA Participation [​](/content/blog/technical-guide-to-tefca#incentives-for-tefca-participation "Direct link to Incentives for TEFCA Participation"/index.html)

Participating in TEFCA offers several incentives for healthcare organizations:

• Regulatory Requirements: TEFCA aligns with federal regulations and may be required for participation in certain government programs6.
• Value-Based Care: TEFCA facilitates data exchange necessary for value-based care models, enabling care coordination and improved patient outcomes6.
• Improved Patient Care: TEFCA enables access to a more complete patient record, leading to better clinical decision-making and improved care coordination6.
• Enhanced Interoperability: TEFCA promotes interoperability across different healthcare systems, enabling seamless data exchange and reducing administrative burden6.
• Public Health Reporting: TEFCA facilitates public health reporting, enabling the electronic submission of case reports and other critical data6.
• Competitive Advantage: TEFCA participation can provide a competitive advantage by demonstrating a commitment to interoperability and data exchange6.

Data Governance and Compliance [​](/content/blog/technical-guide-to-tefca#data-governance-and-compliance "Direct link to Data Governance and Compliance"/index.html)

TEFCA emphasizes data governance and compliance to ensure the responsible and secure exchange of health information. Key considerations include:

• Data Quality Control: QHINs and their participants are responsible for implementing data quality control measures to ensure the accuracy and reliability of exchanged data17.
• Data Storage: QHINs generally act as pass-throughs for data and do not store it. Participants and Subparticipants become stewards of the data they consume and are responsible for its storage and use in compliance with HIPAA and other applicable laws17.
• Legal Considerations: Agreements between QHINs, Participants, and Subparticipants address how information will be exchanged and do not alter existing legal authority for accessing or sharing data17.

Operational Considerations [​](/content/blog/technical-guide-to-tefca#operational-considerations "Direct link to Operational Considerations"/index.html)

When connecting to a QHIN, organizations should consider the following operational aspects:

• Network Traffic: QHINs are designed to handle high volumes of transactions, but organizations should monitor network traffic and potential bottlenecks17.
• Data Quality Issues: Organizations should have processes in place to address potential data quality issues and escalate concerns to the RCE if necessary17.
• Dispute Resolution: Organizations should be familiar with the TEFCA dispute resolution process for resolving any issues or disagreements that may arise17.

The Evolving Landscape and Future of TEFCA [​](/content/blog/technical-guide-to-tefca#the-evolving-landscape-and-future-of-tefca "Direct link to The Evolving Landscape and Future of TEFCA"/index.html)

TEFCA is shaping the future of healthcare interoperability, and its landscape is constantly evolving.

The Role of Epic and Other EHR Vendors [​](/content/blog/technical-guide-to-tefca#the-role-of-epic-and-other-ehr-vendors "Direct link to The Role of Epic and Other EHR Vendors"/index.html)

Epic, a leading EHR vendor, plays a significant role in TEFCA. Epic has developed its own QHIN, Epic Nexus, to facilitate TEFCA participation for its customers18. As of December 2024, Epic Nexus has connected 625 hospitals to the TEFCA network18. This demonstrates the commitment of EHR vendors to supporting TEFCA and promoting nationwide interoperability.

The Future of Carequality and CommonWell [​](/content/blog/technical-guide-to-tefca#the-future-of-carequality-and-commonwell "Direct link to The Future of Carequality and CommonWell"/index.html)

Carequality and CommonWell, two major health information exchange frameworks, are aligning their strategies with TEFCA19. Carequality is enhancing its framework to bolster trust and plans to converge with TEFCA in the future19. CommonWell, now a designated QHIN, is actively collaborating with TEFCA to improve data exchange and interoperability20. This convergence of existing frameworks with TEFCA will further strengthen nationwide interoperability and streamline data exchange.

Emerging Use Cases [​](/content/blog/technical-guide-to-tefca#emerging-use-cases "Direct link to Emerging Use Cases"/index.html)

TEFCA is enabling new and innovative use cases for health information exchange. Some examples include:

• Electronic Case Reporting: TEFCA facilitates electronic case reporting to public health agencies, enabling the automated transmission of case reports and supporting public health surveillance21.
• Public Health Data Exchange: TEFCA enables public health agencies to access and exchange data for various purposes, such as case investigations, syndromic surveillance, and immunization reporting21.
• HEDIS Reporting: TEFCA is being explored for HEDIS reporting, potentially streamlining data collection and reducing the burden associated with quality measurement22.

These emerging use cases demonstrate the potential of TEFCA to transform healthcare interoperability and improve various aspects of healthcare delivery and public health.

Benefits of TEFCA for Developers [​](/content/blog/technical-guide-to-tefca#benefits-of-tefca-for-developers "Direct link to Benefits of TEFCA for Developers"/index.html)

TEFCA offers several benefits for software developers:

• Facilitating Innovation: TEFCA provides a standardized framework for data exchange, removing barriers to innovation and enabling the development of new technologies and applications2.
• Reducing Administrative Burden: TEFCA streamlines data exchange processes, reducing administrative burden and allowing developers to focus on building and improving healthcare solutions2.
• Promoting the Development of New Technologies: TEFCA fosters a collaborative environment for developing new technologies and applications that leverage interoperable health data2.

Challenges and Opportunities of TEFCA [​](/content/blog/technical-guide-to-tefca#challenges-and-opportunities-of-tefca "Direct link to Challenges and Opportunities of TEFCA"/index.html)

While TEFCA presents a significant opportunity for improving healthcare interoperability, there are also challenges to consider:

• Implementation Complexity: Implementing TEFCA requires careful planning and coordination to ensure compliance with technical specifications, governance policies, and security requirements10.
• Stakeholder Alignment: Achieving widespread adoption of TEFCA requires alignment and collaboration among various stakeholders, including healthcare providers, payers, health IT vendors, and government agencies10.

Despite these challenges, TEFCA offers a unique opportunity to create a more connected and interoperable healthcare system, leading to improved patient care, enhanced efficiency, and greater innovation.

Security Considerations [​](/content/blog/technical-guide-to-tefca#security-considerations "Direct link to Security Considerations"/index.html)

TEFCA prioritizes security and privacy, requiring QHINs and their participants to implement robust security controls23. These include:

• HIPAA Compliance: QHINs and participants subject to HIPAA must comply with its privacy and security rules23.
• Data Encryption: All entities must encrypt individually identifiable information, both in transit and at rest23.
• Cybersecurity Measures: QHINs must implement cybersecurity measures, including annual technical audits, penetration testing, and incident reporting23.
• Identity Proofing and Authentication: TEFCA requires strong identity proofing and authentication mechanisms to ensure secure access to health information23.

These security measures help protect patient data and maintain the integrity and trustworthiness of the TEFCA exchange ecosystem.

Conclusion [​](/content/blog/technical-guide-to-tefca#conclusion "Direct link to Conclusion"/index.html)

TEFCA represents a significant advancement in healthcare interoperability, establishing a nationwide framework for secure and efficient data exchange. By connecting various health information networks and their participants, TEFCA enables seamless access to patient information, improves care coordination, and promotes innovation in healthcare.

Software developers and healthcare IT professionals play a crucial role in integrating systems with TEFCA. By understanding the technical specifications, governance policies, and security requirements of TEFCA, they can ensure their applications and organizations are TEFCA-compliant and leverage its benefits.

Medplum offers a valuable platform for organizations seeking to participate in TEFCA. Its integration engine, FHIR support, and security features facilitate QHIN connectivity and enable the development of interoperable healthcare solutions.

The evolving landscape of TEFCA, with the participation of major EHR vendors and the alignment of existing HIE frameworks, further strengthens the foundation for nationwide interoperability. Emerging use cases, such as electronic case reporting and public health data exchange, demonstrate the potential of TEFCA to transform healthcare and improve patient outcomes.

We encourage healthcare organizations and developers to embrace TEFCA and contribute to the development of a more connected and interoperable healthcare ecosystem.

Glossary of Terms [​](/content/blog/technical-guide-to-tefca#glossary-of-terms "Direct link to Glossary of Terms"/index.html)

Works cited [​](/content/blog/technical-guide-to-tefca#works-cited "Direct link to Works cited"/index.html)

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18. Health Systems Using Epic Have Connected 625 Hospitals to the ..., accessed February 16, 2025, https://www.epic.com/epic/post/health-systems-using-epic-have-connected-625-hospitals-to-the-tefca-interoperability-framework-in-one-year/

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20. About CommonWell, accessed February 16, 2025, https://www.commonwellalliance.org/about/

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Footnotes [​](/content/blog/technical-guide-to-tefca#footnotes "Direct link to Footnotes"/index.html)

Footnotes [​](/content/blog/technical-guide-to-tefca#footnote-label "Direct link to Footnotes"/index.html)

1. Framework for Public Health Interoperability - Version 2.1 Published. NACCHO. (n.d.). Retrieved February 16, 2025, from https://www.naccho.org/blog/articles/tefca-ver-2.1-published ↩ ↩2 ↩3 ↩4 ↩5

2. Health Data, Technology, and Interoperability: Trusted Exchange Framework and Common Agreement (TEFCA) Rule. Federal Register. (2024, December 16). Retrieved February 16, 2025, from https://www.federalregister.gov/documents/2024/12/16/2024-29163/health-data-technology-and-interoperability-trusted-exchange-framework-and-common-agreement-tefca ↩ ↩2 ↩3 ↩4

3. Trusted Exchange Framework and Common Agreement (TEFCA). HealthIT.gov. (n.d.). Retrieved February 16, 2025, from https://www.healthit.gov/topic/interoperability/policy/trusted-exchange-framework-and-common-agreement-tefca ↩ ↩2 ↩3

4. Common Agreement - ONC TEFCA RCE. The Sequoia Project. (n.d.). Retrieved February 16, 2025, from https://rce.sequoiaproject.org/common-agreement/ ↩ ↩2

5. TEFCA Overview and Perspectives Slides (April 2024). Association of State and Territorial Health Officials (ASTHO). (2024, April). Retrieved February 16, 2025, from https://www.astho.org/48f67a/globalassets/pdf/tefca-overview-and-perspectives-slides-april-2024.pdf ↩ ↩2 ↩3 ↩4 ↩5 ↩6 ↩7 ↩8 ↩9 ↩10 ↩11

6. TEFCA Data Sharing and Implementation Centers. CDC Foundation. (n.d.). Retrieved February 16, 2025, from https://www.cdcfoundation.org/TEFCADataSharingandImplementationCenters-JimJirjis.pdf?inline ↩ ↩2 ↩3 ↩4 ↩5 ↩6 ↩7 ↩8 ↩9 ↩10

7. Understanding TEFCA: Key Changes and Impacts on Healthcare in 2025 and Beyond. Productive Edge. (n.d.). Retrieved February 16, 2025, from https://www.productiveedge.com/blog/understanding-tefca-key-changes-and-impacts-on-healthcare-in-2025-and-beyond ↩ ↩2 ↩3 ↩4 ↩5 ↩6

8. Epic TEFCA Alignment: Key Takeaways for Development Companies. Vitamin Software. (n.d.). Retrieved February 16, 2025, from https://vitaminsoftware.com/blog/epic-tefca-alignment-key-takeaways-for-development-companies ↩

9. The Trusted Exchange Framework and Common Agreement (TEFCA) and Blockchain Technology. National Library of Medicine. (2024). Retrieved February 16, 2025, from https://pmc.ncbi.nlm.nih.gov/articles/PMC10785864/ ↩ ↩2 ↩3

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12. Medplum Integration. (n.d.). Retrieved February 16, 2025, from https://www.medplum.com/products/integration ↩

13. Medplum FHIR Datastore. (n.d.). Retrieved February 16, 2025, from https://www.medplum.com/products/fhir-datastore ↩

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25. QHIN Technical Framework (QTF) Version 2.0. The Sequoia Project. (2024, July). Retrieved February 16, 2025, from https://rce.sequoiaproject.org/wp-content/uploads/2024/07/QTF-v2.0_508.pdf ↩ ↩2 ↩3 ↩4 ↩5 ↩6 ↩7 ↩8 ↩9 ↩10 ↩ ↩2 ↩3 ↩4 ↩5 ↩6 ↩7 ↩8 ↩9 ↩10

• Purpose
• Background
• Understanding the TEFCA Framework
  • TEFCA Goals
  • Trusted Exchange Framework (TEF) Principles
  • TEFCA Architecture
  • Qualified Health Information Networks (QHINs)
  • Data Exchange Methods
  • Patient Matching in TEFCA
• Key Considerations for QHIN Connectivity
• Medplum & TEFCA
  • Addressing the Gaps
  • Medplum's Value Proposition
• Incentives for TEFCA Participation
• Data Governance and Compliance
• Operational Considerations
• The Evolving Landscape and Future of TEFCA
  • The Role of Epic and Other EHR Vendors
  • The Future of Carequality and CommonWell
  • Emerging Use Cases
• Benefits of TEFCA for Developers
• Challenges and Opportunities of TEFCA
• Security Considerations
• Conclusion
• Glossary of Terms
• Footnotes