In late January when I wrote a story about an ONC presentation on its draft Trusted Exchange Framework and Common Agreement (TEFCA), I chose the headline, “What Will TEFCA Mean for Regional HIEs?” because right away it seemed obvious to me that HIEs might see this as more of a threat than an opportunity.
As the public comments came pouring in to ONC, I noticed that several zeroed in on the definition of Qualified Health Information Network (QHIN). During the webinar I covered, Genevieve Morris, principal deputy national coordinator for health information technology, said “What we want to hammer home a bit is that a single regional HIE is unlikely to be a QHIN. Likewise, a single EHR vendor network would likely not qualify as a QHIN. Again, that has to do with trying to create fairness in the marketplace as well as seeking to have a very small number of QHINs to support scalability.”
I want to highlight a few of the critiques, questions and recommendations that one HIE and another interoperability group sent in. Some focus on HIE financial sustainability. Great Lakes Health Connect (GLHC), the statewide HIE for Michigan, noted that, “hundreds of millions were spent collectively over a number of years to establish the core interoperability capabilities within HIEs and other interoperability frameworks across the country.”
“Recreating many of these capabilities in another network layer, further removed from end participants, would take another large number of millions to implement with no context to end-participant value or willingness to pay going forward,” GLHC wrote.
“Further, it is not accounted for in the proposal how this duplicative investment would affect HIEs working with end participants on solving the full local interoperability puzzle. GLHC recommends that ONC leverage the interoperability investments made over the years and not establish a significant financial burden within the industry through a new interoperability layer without an eye to how it would be funded. It is true that QHIN organizations may ‘figure it out’ or just fund it out of their own or sponsor profits. However, if ONC encourages an environment where deeper-pocket organizations with a focus on just one piece of the interoperability puzzle creates sustainability challenges for the very nonprofit HIE organizations making interoperability real in local communities all over the country, we will have gone substantially backwards in many ways.”
The Sequoia Project, the nonprofit organization that houses the eHealth Exchange network and Carequality, also focuses in on the definition of QHIN, and finds it wanting. “As currently defined, with a narrow, standardized and prescriptive definition, it is unclear whether any existing HIN could qualify as a QHIN due to the specific architecture prescribed for query-based exchange and the use cases contemplated,” the Sequoia Project writes. “We and others in the field believe that such TEF provisions, as proposed, may discourage HINs from participating as QHINs.
The existence of too few QHINs could have several negative consequences, including excessive QHIN market power and too few recipients for queries and other exchange models, it noted.
Sequoia also wonders whether there is sufficient demand for the narrow definition of QHIN services among prospective participants and end users. “Forcing such demand through likely pressures/incentives to sign the TEFCA, without adding flexibility, may result in added costs in the healthcare system and ‘bake in’ a very specific architecture, with a likely reduction of innovation and experimentation.”
And although it said it agrees with the principle of participant neutrality, Sequoia questioned ONC’s move to exclude existing HINs (for example, a statewide HIE or a vendor network) that already support query-based exchange at nationwide scale and that could engage in a TEFCA model as a QHIN, from being permitted to participate as QHINs.
“Excluding a single-state HIE but allowing two single state HIEs to collaborate as a QHIN, or excluding a vendor network that has a Connectivity Broker and is willing and able to comply with the Common Agreement seems arbitrary,” Sequoia wrote. “Such an exclusion would force many providers and HINs to change from their existing approach, revise their architecture, and redirect transactions through a QHIN. For providers and HINs that leverage federated approaches, for instance, this requirement would likely add another layer of cost and overhead and could potentially disrupt current exchange, with little additional value from connection to a QHIN.”
(By the way, on Thursday March 1, at 1 p.m. Eastern time, the Sequoia Project is holding a webinar to go over its TEFCA comments.)
As Managing Editor Rajiv Leventhal mentioned in a previous article, several industry groups, including CHIME, suggested that ONC open up an additional comment period this year before finalizing the TEFCA. Although there is general approval of the concept, many stakeholders have expressed concern about the timeline and specifics. Perhaps extending the comment period wouldn’t be a bad idea if ONC really wants buy-in.