What Most Healthcare Vendors Get Wrong About TEFCA Compliance

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Your Health Magazine

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What Most Healthcare Vendors Get Wrong About TEFCA Compliance

TEFCA, the Trusted Exchange Framework and Common Agreement, entered operational status in December 2023 to enable secure nationwide health data exchange. However, many healthcare vendors continue to misinterpret its reach, treating it as another technical interface instead of a multi-faceted interoperability solution.

These misunderstandings lead to delays in QHIN onboarding, misalignment with client expectations, and missed market opportunities. This blog highlights the most frequent vendor errors and offers practical steps to become TEFCA-ready without rework.

2. TEFCA Overview

TEFCA combines a legal Common Agreement, technical standards, and operational policies to support Qualified Health Information Networks (QHINs) and their Participants. It aims to reduce the burden of maintaining numerous point-to-point interfaces and drive broader interoperability efficiencies.

TEFCA standardizes:

• Legal commitments via the Common Agreement and its SOPs
• Interoperability through FHIR, IHE, and C-CDA technical frameworks
• Patient identification and record location through centralized or federated approaches

The initial exchange focuses on Treatment (clinical data sharing) and Individual Access Services (patient-directed requests). Additional use cases like payment and public health access are planned for later stages.

TEFCA is a structured governance model, legal framework, and national interoperability solution rolled into one.

3. Common Vendor Missteps and How to Correct Them

3.1 Treating TEFCA as a Technical API Requirement

Mistake
Vendors often assume TEFCA is just a technical layer, perhaps another FHIR endpoint to support. They may begin coding before reviewing TEFCA policies, SOPs, or legal obligations.

Reality
TEFCA compliance requires legal readiness before technical integration. Organizations must sign the Common Agreement, enact SOPs for consent, audit logging, breach response, and incident reporting.

Fix
Begin with a legal and organizational audit. Documentation requires SOPs and legal clauses. Ensure board-level commitment before hiring developers or building exchange workflows.

3.2 Overlooking Patient Matching and Demographic Normalization

Mistake
Assuming that matching patients across networks is straightforward, relying on local EHR master patient indexes alone.

Reality
TEFCA requires patient matching at QHIN scale, across diverse systems. Many QHINs will use centralized referential engines to align identity resolution—because in-network MPI solutions struggle with accuracy across heterogeneous data.

Fix
Normalize demographics upstream: standardized addresses, phone numbers, and optional fields like email or SSN. Work with QHINs to test match rates. Consider planned identity DNS frameworks and referential match engines in your architecture.

3.3 Misunderstanding Exchange Purposes

Mistake
Some vendors build full-blown support for all potential TEFCA use cases—including billing, research, or public health—before those are finalized or mandated.

Reality
TEFCA’s current scope covers only Treatment and Individual Access Services. Other uses such as research, payments, and public health exchanges are under development and are not yet required.

Fix
Map your workflows to the current required purposes. Design your system to accommodate future expansion without over-engineering today. Clearly document current and future support to clients and compliance teams.

3.4 Ignoring QHIN Dynamics and Market Pressure

Mistake
Some vendors delay TEFCA adoption because participation is not yet mandatory. They view it as a compliance project with no urgency.

Reality
While technically voluntary, TEFCA is quickly becoming de facto mandatory in networks led by dominant EHR vendors and large health systems. Epic, for example, has launched its own QHIN (Epic Nexus) and is encouraging customers to align with it. Vendors who ignore QHIN strategies risk exclusion from future data exchange ecosystems.

Fix
Identify which QHINs your clients are joining. Begin discussions with at least two QHINs to understand their technical and policy expectations. Build QHIN-agnostic capabilities into your product and avoid relying on a single interoperability channel.

3.5 Underestimating Multi-Network Coexistence

Mistake
Assuming that TEFCA will replace existing networks like Carequality, DirectTrust, or regional HIEs and planning to deprecate older interfaces prematurely.

Reality
TEFCA will coexist with existing networks for the foreseeable future. Clients may need parallel access to both TEFCA-based and non-TEFCA exchanges, especially during the transition phase.

Fix
Build flexible routing and network selection logic into your architecture. Allow customers to configure their preferred exchange paths (TEFCA, Direct, Carequality, etc.) based on data type, trading partner, or trust agreements. This reduces disruption and preserves continuity.

3.6 Neglecting SOPs, Security, and Identity Proofing

Mistake
Focusing purely on APIs and ignoring the Standard Operating Procedures (SOPs) defined in the Common Agreement, which cover data handling, consent, breaches, and access audits.

Reality
TEFCA compliance extends beyond HIPAA. Some data shared under Individual Access Services may go to non-HIPAA-covered entities. Additionally, QHINs require strict identity assurance measures, encryption standards, and auditability.

Fix
Perform a security gap analysis across encryption, breach response, and data retention policies. Ensure OAuth 2.0 and identity proofing flows align with NIST IAL2/IAL3 requirements where needed. Prepare internal teams to operationalize TEFCA’s SOPs—not just code for them.

3.7 Failing to Track TEFCA’s Evolving Technical Stack

Mistake
Assuming that today’s IHE-based exchange format is the final state of TEFCA and delaying investment in modern APIs.

Reality
The Sequoia Project, which governs TEFCA’s implementation, has already confirmed that FHIR-based exchange at the QHIN level is on the roadmap. As Common Agreement versions evolve, future compliance will require support for bulk FHIR, flat NDJSON exports, and possibly REST-based TEFCA endpoints.

Fix
Don’t stop at C-CDA or XCA. Begin building support for FHIR R4 APIs with dynamic metadata handling. Monitor TEFCA Technical Framework (QTF) releases and prepare your engineering roadmap for phased FHIR adoption. Treat current IHE capabilities as a foundation, not a final solution.

4. Strategic Roadmap for Vendors Adopting TEFCA

To avoid rework and stay ahead of regulatory and market trends, healthcare vendors should adopt a phased but comprehensive TEFCA enablement strategy. Key steps include:

• Legal onboarding: Review and align with the Common Agreement and required SOPs.
• Patient matching readiness: Standardize demographic inputs and validate match accuracy across QHIN-level datasets.
• Workflow scoping: Limit current focus on Treatment and Individual Access Services while preparing for future exchange purposes.
• QHIN engagement: Evaluate available QHINs based on customer alignment, onboarding time, and technical compatibility.
• Flexible routing: Build support for multi-network participation across TEFCA, HIEs, and Carequality.
• Security alignment: Meet encryption, logging, and identity verification requirements beyond HIPAA.
• FHIR planning: Begin integrating FHIR endpoints for long-term TEFCA scalability.

5. Conclusion and Practical Next Steps

TEFCA redefines nationwide data sharing by uniting legal agreements, technical formats, and operational policies in a single framework. Treating it as a routine API upgrade leaves critical gaps: patient matching errors, untested security workflows, and misaligned exchange purposes. Those gaps surface when QHIN contracts, client RFPs, and audit teams start asking detailed questions.

A vendor should pay equal attention to policy and code. That means:

1. Validate legal readiness
   Confirm your organization can sign the Common Agreement and adopt its Standard Operating Procedures without exception.
2. Tighten identity and consent mechanics
   Standardize demographic fields, verify match rates with live QHIN sandboxes, and document consent flows for Treatment and Individual Access Services.
3. Future-proof the technical stack
   Layer FHIR R4 endpoints and bulk-data exports onto existing IHE transactions, so your product scales with forthcoming QTF updates.
4. Build multi-network routing logic
   Support TEFCA alongside Care Quality, Direct Trust, and regional HIEs, letting clients decide the optimal exchange path.

Start with a formal readiness assessment, close the gaps in each area, and deliver interoperability solutions that not only meets TEFCA requirements, but strengthens long-term scalability and trust across the healthcare ecosystem.