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Todd Shryock, contributing author
What the TEFCA announcement means for interoperability and doctors long-term.
In early January, the Office of the National Coordinator for Health Information Technology (ONC) released a draft of the Trusted Exchange Framework and Common Agreement (TEFCA), a set of guidelines for how information can be exchanged as part of an effort to move the healthcare industry toward interoperability.
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Medical Economics recently spoke with David Kibbe, MD, the president and chief executive officer of DirectTrust, a nonprofit association of 121 health IT and healthcare provider organizations that support interoperable health information about the announcement and what it means for both interoperability and the doctors that need it.
David Kibbe, MD
Medical Economics: In simple terms, what is TEFCA and what does it do?
David Kibbe: ONC was required by Congress as part of the 21st Century Cures Act to develop the Trusted Exchange Framework and its accompanying Common Agreement, which together aim to create a common set of principles for trusted exchange of electronic health information as well as minimum terms and conditions that healthcare providers must meet when exchanging health information. The framework aims to create a technical and governance infrastructure that connects disparate health information networks together through a core of “qualified health information networks,” those networks that have pledged to follow the terms of TEFCA.
TEFCA is a draft regulation for public comments due Feb. 20, 2018. As far as we can tell, it is an ambitious proposal that aims to increase health information exchange in three areas: patient access to their health records, population-level data for analysis and research, and entrepreneurial innovation through requiring the use of open and accessible FHIR APIs (Application Programing Interfaces that would allow devices like iPhones to be able to call up and deliver one’s health data.)
Physicians have been waiting on true interoperability for years. Does TEFCA move the industry any closer to interoperability and is this good for doctors?
DK: Not in the short term, no. But it may raise the bar. TEFCA addresses specific types of exchanges of information between what ONC defines as “qualified [Health Information Network (HIN)].” If physicians live in an area of the country where there is a Health Information Exchange (HIE) and if that HIE becomes a qualified HIN under the terms of TEFCA, then they and their patients may find that this eventually increases the ease of access they will have to health information, and extends that access to health data stored in other qualified HINs across the country.
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This could take several years to roll out. Participation in this new group of qualified HINs would be voluntary. However, the qualified HINs who sign the Common Agreement would be legally bound to be governed, and have the terms of the agreement enforced by a newly coined organizational entity, the Recognized Collaborating Entity, or RCE. Through a competitive bidding process, the RCE will be selected by ONC and funded through a multi-year cooperative agreement. So, all of this will take time to develop, and ONC is just starting the process with these draft regulations for public comment.
HHS said that with these guidelines, whenever possible, they built on technology infrastructure/agreements that were already in place. Will existing health information exchanges be affected by this, and what will that mean for the doctors who use them today?
DK: That is the big question. Because TEFCA is a voluntary program, existing information exchanges will be affected only if they choose to abide by the new rules that govern participation. Although TEFCA seeks to be built on current standards and infrastructures, HIEs will need to carefully consider what modifications to existing participation agreements and trust frameworks will be necessitated to support provisions such as the additional permitted disclosures of health information by the qualified HINs. And they will need to weigh the additional resources they may need in their networks to make upgrades to meet new mandated IT capabilities and align to certain trust and security practices. This evaluation will take some time.
This is why it is very important that HIEs and the physicians using them engage in public comment over the next few weeks so that the planners at ONC get good feedback about possible disruptions to current HIE networks and their agreements that might result.
Do you see TEFCA as being able to eventually provide the “single on-ramp” to health information the administration says it wants to create?
DK: It’s a stretch of the imagination, but it might be possible if enough qualified [networks] choose to participate. Right now, only about 30 percent of hospitals in the U.S. participate in an HIE, and most HIEs are located in or near large metropolitan areas, leaving many rural areas without HIEs. So, even if all of the 100 or so existing HIEs in this country were to adopt the TEFCA rules and offer a single “on-ramp” to an end-user-allowing him or her access to all the data in all the HIEs through a single account-there would be large gaps in whose data was accessible.
If the TEFCA rules were to extend to all hospitals, all medical practices, all pharmacies, all clearinghouses and all payers, then I think a single on-ramp would stand a greater chance of becoming a reality and having a significant impact on interoperability.
Final TEFCA rules are supposed to be completed by the end of this year and operations in place by the end of next year. Is that realistic considering the amount of work that needs to be done? Can doctors expect to see interoperability by 2020?
DK: Again, it all depends on the extent of participation of the qualified HINs and at what rate they sign the Common Agreement and implement its terms. And it depends on what you consider “interoperability” to be. TEFCA deals only with calls to gather information, known as queries, not with sending of information as is done with Direct exchange or fax. The use-cases under the terms of TEFCA are only those where information for a single patient or a group of patients is sought by someone in the network. So, if successful, TEFCA would boost queries for health information exchange, but not necessarily full interoperability at the EHR level in the doctor’s office. There is nothing in TEFCA that would, for example, address improving the usability of Direct exchange by EHR vendors, which we know is a real challenge with some doctors and practices and their vendors around the country.
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The framework is voluntary. Is there any guarantee that existing (or future) networks will sign on to the agreement? What would the incentive be to do so (or the disincentive not to)?
DK: It is unclear at this time what might be the incentives for a health information network or HIE to become a qualified HIN. TEFCA does not include any payment incentives for adoption and use as did the Meaningful Use and MIPS programs. One has to ask the obvious question as to why the free market hasn’t developed a TEFCA-like network before this, and what new incentives the TEFCA rules will add that was missing in order to bring it into existence. In addition to lacking a carrot, I don’t see any big sticks that would motivate TEFCA participation, either.
Is there anything within TEFCA that will help doctors sort and identify the data they need to provide quality care? Getting more information from other providers and networks is great, but if all the data arrives in different formats and isn’t sorted in some logical fashion, how valuable will it be?
DK: TEFCA does include standards for data formatting and does aim at making it easier for provider organizations, e.g. Accountable Care Organizations, to seek information on panels of patients in order to better manage and coordinate care.
Are there any other ways you see TEFCA eventually affecting the day-to-day operations of a smaller practice?
DK: Small practices connected to a TEFCA-qualified HIN might eventually find it easier for themselves and their patients to access, download and transport health records in standardized and computable formats like FHIR and the CCDA. If FHIR APIs become more common, this would further enable queries from smart phones and other devices to extract and manage specific kinds of information, e.g. medications or lab results. Whether this would affect and improve daily operations in the medical practice will have to be seen, and will depend greatly on the volunteer participation in TEFCA over the next couple of years.
David Kibbe, MD, is president and chief executive officer of DirectTrust. a collaborative nonprofit association of 121 health IT and health care provider organizations supporting secure, interoperable health information exchange via the Direct message protocols.