So imagine your brother heads to Los Angeles from his home in San Francisco one weekend to join you at a Dodgers game, and while at the stadium, he gets hit in the head by a baseball. You rush your brother to the emergency department (ED), where he is unable to answer questions about his medications or medical history. The ED physician asks you about your brother’s health history, but you have no idea about his medications, allergies, recent surgeries, or the name of his primary care provider. If the ED physician could have accessed this information, he might have been able to expedite treatment and improve your brother’s chance for a full recovery. Without this information, ED physicians will have to evaluate your brother from the beginning.
For over 30 years, the United States government and various regional healthcare institutions have been trying to facilitate the secure electronic movement of patient health information between organizations in accordance with a set of nationally recognized standards. The idea being that timely sharing of health information can improve the quality of healthcare, improve provider efficiency and patient safety, and give clinical research and public health programs a macro-level view of healthcare, which should ultimately lead to better care for all Americans.
Evolution of Health Level 7
The first attempt to share information within and between hospitals was in the form of Health Level 7 (HL7). Formed in the late 1980s, HL7 is a standards group of providers and vendors that established a messaging protocol for the exchange of health information between different systems. HL7 has had many iterations, including the latest version, HL7 Fast Healthcare Interoperability Resource (HL7 FHIR), but the most widely used version still in use today is HL7v2, which was established in the early 1990s. HL7’s functionality allows for exchanging orders; tracking patient admits, discharges, and transfers; patient search; sharing lab results; and filing charges for procedures. While HL7 has made it simpler for communication inside and within systems and hospitals, it’s done little to ease the burden of sharing data across disparate health systems.
Health Information Exchanges
Another common case that the US has been trying to solve has been the transfer of care from rural to urban settings, so being able to enable seamless integration of clinical care documents is another problem governments are eager to tackle. Health Information Exchanges (HIEs), were established to solve this problem by setting a standard for all member hospitals within a region or state to conform to a specific set of clinical data exchange rules. Over time, nearly every state in the US has implemented one or more health information exchanges where a group of member hospitals can exchange care documents on patients.
The development of HIEs and their role in advancing interoperability at the regional level made it clear that national standards needed to be developed, which led to the creation of nationwide Health Information Exchanges such as eHealth Exchange in 2007 (initially launched as NwHIN, Nationwide Health Information Network), the CommonWell Health Alliance in 2013 and then Carequality in 2016.
eHealth Exchange was formed in part to allow the exchange of information between federal agencies, HIEs, and then health systems, CommonWell was formed by a few companies that developed Electronic Health Records Systems (EHRs), and then Carequality brought together HIEs and EHRs. Now all of these nationwide exchanges essentially share data with each other through Carequality.
In 2016, the Office of the National Coordinator for Health Information Technology (ONC), a division of the US Department of Health and Human Services (HHS), called for the creation of TEFCA under the 21st Century Cures Act. The ONC’s primary role is to promote the adoption and effective use of health information technology and facilitate the nationwide exchange of health information. TEFCA stands for Trusted Exchange Framework and Common Agreement, and its primary goal is to establish a nationwide health information exchange framework that promotes interoperability, privacy, and security protections while also enabling the secure exchange of health information across different health networks and organizations.
As the name TEFCA implies, it comes in two parts, the Trusted Exchange Framework, which are the technical details for how data sharing is done, and the Common Agreement, which is a legal agreement that governs data sharing between networks. Health Information Exchanges or Networks can then apply to be certified as a QHIN (Qualified Health Information Network). This certification body was established in 2012 and is called The Sequoia Project. The Sequoia Project is a public/private entity of neutral stakeholders who are attempting to promote the secure exchange of electronic health information, and they currently administrate eHealthExchange and Carequality, two nationwide interoperability frameworks for sharing health information.
You can think of TEFCA as a nationwide network of Qualified Health Information Networks that meet the base level requirements of common data exchange. If widely adopted (and all indications are that TEFCA will promote meaningful adoption soon), when your brother gets hit by that baseball while on vacation, or you need to have your care transferred from a rural site to an urban setting, your patient records will be much more easily obtainable allowing providers to treat you more quickly and accurately.
Ongoing Challenges with TEFCA
While many healthcare leaders are excited about TEFCA, there are many stakeholders that believe that TEFCA could have been more aggressive, as the criteria for the Trusted Exchange Framework is voluntary (see public comments on TEFCA). Furthermore, HL7 and FHIR for which these standards were built upon, allow health systems to take a piecemeal approach to deciding what they want to implement. This means coverage for specific healthcare data exchange use cases beyond the core required scenarios of Patient Search and Clinical Summary Document Exchange may require substantial negotiation and additional implementation time between health systems looking to exchange data.
This additional time can add delays of months to a workflow being enabled, breaking the promise of seamless nationwide exchange. Health systems need vendors with multi-layered approaches to exchange data; without it, physicians may not get the information they need and as a result, end up spending 20 minute of a 30-minute appointment just doing a med reconciliation.
Impact of COVID-19 and the Future of TEFCA
The COVID-19 pandemic accelerated the adoption of telehealth and the need for remote providers to be able to access patient records when connecting with a patient over video for the first time. Seamless access to a patient’s records before or during the telehealth call has the potential to greatly improve physician productivity, making it easier to quickly diagnose conditions and prescribe treatments, which ultimately results in a better patient experience.
In the US we have made steady progress facilitating the seamless exchange of medical records beginning with HL7, Regional HIEs, nationwide Health Information Networks such as eHealth Exchange, CommonWell, Carequality. Now with TEFCA we’re going to see the base level of requirements rise, which is good for providers and patients across the country, but we can’t stop here.
We still need to push for more consistent adoption. We need more health systems to fully participate and we need to prevent rural facilities from getting left behind. This is the only way we can ensure equitable access to quality healthcare for everyone. Not only should your brother be able to get great care when he gets hit by a baseball, all of his relevant medical records should be easily accessible in a moment’s notice to maximize the chance of a positive patient outcome.