The Trusted Exchange Framework and Common Agreement (TEFCA) took a big step forward on April 22, 2024 when ONC published the long-expected Common Agreement v. 2.0.  Many people, Steve Gravely included, have been working diligently to update the Common Agreement even while the first group of Designated QHINs started exchanging health information live via TEFCA earlier this year. 

The Common Agreement is the binding, legal trust agreement that every Designated QHIN signs with the ONC Recognized Coordinating Entity (RCE).  But the impact of the Common Agreement extends far beyond the QHINs and it affects everyone who participates in TEFCA at every level and, literally, the millions of Americans whose information is shared via TEFCA.  For those who are not directly immersed in TEFCA, here are some key takeaways about Common Agreement v. 2.0.

• More SOPs-A lot of the operational details about TEFCA have been taken out of the Common Agreement and placed in new Standard Operating Procedures (SOPs).  Not only does this “declutter” the Common Agreement, it allows these operational details to be more easily updated through the Change Management Process.  We all know how rapidly things change in health information exchange and TEFCA needs to be nimble; SOPs enable that.  But, these SOPs include a lot of important details and you should review them carefully. 
• Standard Terms of Participation-TEFCA is like an iceberg, while everyone focuses on ONC, the RCE and the QHINs, there is so much more to TEFCA.  None of this works without the hundreds, or thousands, of down-stream organizations like HIE/HINs, health systems, payers and others that hold the information that is being exchanged.  Indeed, TEFCA was designed to leverage these existing networks so that TEFCA could accelerate its adoption across the US.  Prior versions of the Common Agreement required QHINs to “flow-down” specific TEFCA requirements to their customers that participate in TEFCA, but allowed QHINs to tailor these flow-downs to what works best for their current legal and policy eco-system.  Common Agreement v. 2.0 takes away this flexibility in favor of a standardized set of “Terms of Participation” that every QHIN is required to use with all of its TEFCA Participants and their Subparticipants. 
• TEFCA on FHIR-A big part of the Common Agreement v. 2.0 is to specifically incorporate provisions needed to support FHIR-based exchange.  This was absent from earlier versions because FHIR was not “ready for prime time”.  While there is still a lot of debate about whether FHIR can be implemented at scale today, the Common Agreement v. 2.0 incorporates FHIR and the updated QTF v. 2.0 includes FHIR requirements.  We can look forward to new SOPs to support and expand FHIR via TEFCA, so buckle up!
• Opening the gate-A very important part of the Common Agreement 2.0, QTF 2.0 and the new SOPs is to open up TEFCA exchange to new players.   This is a bit subtle, but its pretty obvious once you focus on it.  QHINs and their Participants are allowed to list in the RCE Directory “agents” which are third parties that can use TEFCA exchange to request information via TEFCA on behalf of the agent’s customers.  The argument in favor of allowing these “agents” to use TEFCA is to recognize that these very organizations operate today in the wild and play an important role in helping make health information available.  Others are concerned that these “agents” are not transparent and increase the risk that sensitive health information could be shared inappropriately.  I think that this issue will continue to play-out during 2024 and TEFCA expands. 
• Next Steps?  We expect the Common Agreement v. 2.0 and the Terms of Participation to be published in the Federal Register this week.  This is important because the “Implementation Date” for these changes is 60 days after they are published in the Federal Register.  This means that all of these changes should be implemented in late June-early July 2024.