The ONC’s draft Trusted Exchange Framework and Common Agreement (TEFCA) is an ambitious plan to jolt the sluggish pace of progress on interoperability between providers. But it is voluntary and requires a redefinition of relationships between large players in the industry. It also may force regional health information exchanges to switch focus from just moving data between providers to offering value-added services or risk being put out of business.
On Jan. 23, Genevieve Morris, principal deputy national coordinator for health information technology, spoke during a monthly webinar put on by the Centers for Disease Control to foster collaboration around the public health response to the widespread adoption of EHRs and Meaningful Use.
In the health IT data-sharing landscape today, “everyone has a piece of the puzzle, and that puzzle is not all fitting together,” Morris said. “With the draft TEFCA, we are taking the things that are working well, tweaking them a bit, or supplementing where there is nothing working well, so we can get to something that works well for everyone. I think we can get to a full puzzle, but right now everyone out there has a piece and we really need them to work together, which is the goal of the framework.”
In its “network of networks” approach, TEFCA introduces a new concept of the Qualified Health Information Network. I think a lot of people thought that this was just a new term for the regional and state HIEs that now exchange data. But Morris said they are envisioning just a handful of QHINs, many fewer networks than all the HIOs and HIEs we have now.
“What we want to hammer home a bit is that a single regional HIE is unlikely to be a QHIN,” she said. “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.”
So the HIEs would have to join the TEF through an organization such as the Strategic Health Information Exchange Collaborative (SHIEC). Other examples of potential QHINs would be groups of payers or groups of EHR and analytics vendors.
“We did this to introduce competition at the right place into the market, while also creating a fair playing field for folks who might be disenfranchised right now,” Morris said. “But we also did it for that scalability reason. Without centralized infrastructure, if you are going to support broadcast query, you need a small number of networks connecting to each other.”
This also raises questions about how huge EHR vendor-centric networks such as Epic’s CareEverywhere would respond. On Jan. 30, as I was writing this up, Epic announced more features for its virtual network of Epic users. There are three parts to Epic’s One Virtual System Worldwide:
• Come Together: Gather the data
• Happy Together: Present the combined data in an easy to read format
• Working Together: Take actions across organizations
On the webinar, Morris was asked what would prevent large national networks from undermining the sustainability of local HIEs. In her response, she was fairly blunt about where the HIE movement has failed.
“I have worked with a lot of HIEs over the past six or seven years and what I can say is that while regional HIEs have done a stellar job connecting hospitals and health systems, the ambulatory space is a different beast entirely,” she said. "My experience is that it takes six to nine months to connect one ambulatory practice. We would never get to nationwide interoperability within 100 years that way. While we have a number of regional HIEs that are doing very well, the amount of white space that has no coverage from a regional HIE is quite significant. As ONC, we have to be concerned about nationwide interoperability above everything else."
She said the framework would allow an opportunity for regional HIEs to serve community and social services and get them access to the data they need without having to connect all the ambulatory practices themselves.
The framework would allow HIEs that are providing really valuable services to their community to have easier access to data, while also enabling the folks who are in white spaces to exchange the data they need to exchange, she added.
To address population health use cases, Morris mentioned that ONC is working with HL7 and the Smart on FHIR team to build out a FHIR spec that will allow people to query for more than one patient record at a time. “In other words, I give you my patient panel, and a broadcast query would be done for all the ePHI, and all the records iwould be sent back n one query instead of having to do them one at a time. We think that is a really important use case, but that standard is just being built now. We know that it is two or three years away.”
The TEFCA is out for public comment until Feb. 20. In spring 2018 ONC intends to put out a funding opportunity announcement for the Recognized Coordinating Entity to oversee the work of QHINs. It expects to have the RCE in place by August so it can move forward with the RCE on the common agreement and release the final framework on the ONC web site and the Federal Register by the end of year. (Who are likely candidates for the RCE? The Sequoia Project’s Carequality? Commonwell Health Alliance?)