TEFCA Integration Services

TEFCA — the Trusted Exchange Framework and Common Agreement — is the federal initiative to create a single, nationwide framework for health data exchange. Developed by ONC (Office of the National Coordinator for Health IT) and managed by The Sequoia Project as the Recognized Coordinating Entity, TEFCA establishes a common set of rules that allow any connected organization to exchange health data with any other connected organization, regardless of which network or EHR they use. For healthcare organizations, TEFCA eliminates the need to negotiate individual point-to-point data sharing agreements and provides a standardized pathway to nationwide interoperability. As TEFCA adoption grows, organizations that are not connected risk being left out of the national data exchange ecosystem.

A QHIN — Qualified Health Information Network — is a top-level network entity designated by the RCE to facilitate nationwide health data exchange under TEFCA. Designated QHINs include CommonWell Health Alliance, eHealth Exchange, Epic Nexus, Health Gorilla, Kno2, KONZA, MedAllies, Netsmart, eClinicalWorks (PrismaNet), Surescripts, and Oracle Health Information Network. Carequality, despite being a long-running interoperability framework, is not itself a designated QHIN — it operates as a separate trust framework. To connect to a QHIN, your organization applies as either a Participant (direct connection) or Sub-Participant (connection through an existing Participant). The process involves completing the QHIN's onboarding application, executing a participation agreement that incorporates the Common Agreement's Minimum Required Terms, implementing the required technical infrastructure, and passing connectivity and conformance testing. Saga IT manages the entire QHIN onboarding process from application through production go-live.

Traditional health information exchanges (HIEs) operate as regional or state-level networks with their own governance, technical standards, and participation agreements. While HIEs have been effective at enabling local data exchange, they often cannot exchange data across network boundaries without additional point-to-point agreements. TEFCA solves this by creating a national framework that connects HIEs, EHR networks, payer systems, and public health agencies under a single Common Agreement. Rather than replacing existing HIEs, TEFCA builds on top of them — many HIEs are connecting to TEFCA through QHIN partnerships, extending their reach from regional to nationwide. Organizations that already participate in an HIE can leverage that relationship to connect to TEFCA more efficiently.

TEFCA defines six exchange purposes that govern why and how health data can be shared: Treatment (direct patient care), Payment (claims and billing), Healthcare Operations (quality improvement), Public Health (surveillance and reporting), Individual Access Services (patient right of access), and Government Benefits (eligibility determination). Most provider organizations start with Treatment and Individual Access Services, as these cover the most common clinical and patient-facing use cases. Payers typically need Treatment, Payment, and Healthcare Operations. Public health agencies focus on the Public Health exchange purpose. Each exchange purpose has specific technical and governance requirements, so we help you determine which exchange purposes align with your organizational needs and implement them incrementally.

A typical TEFCA implementation takes 6 to 12 months from initial assessment to production exchange, depending on your organization's current interoperability maturity and chosen QHIN pathway. Organizations with existing HIE connections and modern FHIR infrastructure can often reach production in 6 to 8 months. Those starting from scratch with legacy systems may need 10 to 12 months. The implementation cost varies based on scope — factors include the number of exchange purposes you support, whether you connect as a Participant or Sub-Participant, the complexity of your existing integration infrastructure, and the extent of identity proofing and patient matching capabilities you need to build. We provide a detailed cost estimate after the initial readiness assessment.

The TEFCA Common Agreement is the legal framework published by the RCE (The Sequoia Project) that governs all data exchange across the TEFCA network. It defines the rights, obligations, and technical requirements for QHINs, Participants, and Sub-Participants. The Minimum Required Terms (MRTs) are the non-negotiable baseline provisions that must be incorporated into every participation agreement throughout the network hierarchy. MRTs cover obligations like responding to valid data queries, protecting privacy in accordance with applicable law, implementing required security controls, and reporting security incidents. The Common Agreement also includes Standard Operating Procedures that define the technical details of how exchange works — message formats, query patterns, identity proofing procedures, and error handling protocols.

CommonWell Health Alliance is a designated QHIN under TEFCA. Carequality, despite being one of the largest pre-TEFCA interoperability frameworks, has not itself been designated a QHIN — it remains a separate trust framework. Many organizations that exchange data via Carequality today reach the broader TEFCA network indirectly: their Carequality connection is bridged through QHINs (like Epic Nexus and others) that participate in both networks. Before TEFCA, Carequality and CommonWell operated as parallel interoperability frameworks with their own governance, and organizations often joined each network independently. Under TEFCA, the QHIN-to-QHIN exchange layer is intended to provide a single national fabric on top of those legacy networks. The result for end users is reduced point-to-point complexity, but the underlying landscape is still a mix of QHIN-designated entities and pre-existing frameworks like Carequality.

TEFCA's technical framework supports FHIR R4 as a primary data exchange standard, and the Common Agreement's Standard Operating Procedures specify FHIR-based query and response patterns for QHIN-to-QHIN exchange. While TEFCA does not exclusively mandate FHIR (some exchange patterns still support other formats), FHIR R4 with US Core profiles is the predominant technical standard for TEFCA exchange. TEFCA and the 21st Century Cures Act are complementary but distinct — the Cures Act established information blocking rules and required certified health IT to support standardized APIs (which led to FHIR-based patient access APIs), while TEFCA provides the national framework for actual cross-network data exchange. Together, they form the regulatory and technical foundation for nationwide health data interoperability.

QHIN selection depends on four primary factors: EHR fit (Epic Nexus is purpose-built for Epic shops; CommonWell has deep Cerner/Oracle Health roots; Carequality is EHR-agnostic), geography & participant base (eHealth Exchange dominates federal + state-government use cases; KONZA leads in Midwest rural and critical-access hospitals; Kno2 is strong in post-acute and ambulatory; Health Gorilla focuses on digital-health vendors and modern API-first platforms), exchange purposes supported (most QHINs cover Treatment, Payment, Operations, and IAS, but Public Health and Government Benefits have variable QHIN support — see the comparison matrix above), and participation tier (whether you join as a Participant directly or as a Sub-Participant under an existing connected organization). We help organizations weigh these factors against current EHR investments, future use cases, and the operational cost of QHIN onboarding.

The Recognized Coordinating Entity (RCE) — currently The Sequoia Project, designated by ONC — is the federally recognized governance body for TEFCA. The RCE doesn't exchange data itself; instead, it administers the Common Agreement, designates new QHINs after rigorous technical and operational review, publishes Standard Operating Procedures (SOPs) governing how exchange works, mediates disputes between QHINs, and collects compliance attestations from designated QHINs. The Sequoia Project also publishes the Minimum Required Terms (MRTs) that flow down through the participant hierarchy, runs annual QHIN recertification, and coordinates the rollout of new exchange purposes (such as the Government Benefits exchange purpose). For organizations evaluating TEFCA participation, the RCE's public materials are the authoritative source for current requirements, SOP versions, and the list of designated QHINs.

Yes, but with variable QHIN coverage by exchange purpose. Payers can use the Payment exchange purpose for claims-supporting documentation and prior authorization (most QHINs support this), and the Healthcare Operations purpose for risk adjustment, HEDIS, and quality reporting. Public health agencies can use the Public Health exchange purpose for case reporting, syndromic surveillance, and immunization registry queries — eHealth Exchange and KONZA have particularly strong public health implementations. Government benefits programs (Social Security Disability, Medicare/Medicaid eligibility, veterans' benefits) use the newest exchange purpose, Government Benefits, which currently has limited QHIN support (eHealth Exchange leads here). For non-Treatment use cases, QHIN selection becomes critical — not every QHIN supports every purpose. We map your specific use case to the QHIN(s) that support it before recommending an onboarding path.