Health Information Exchange and Trusted Exchange Frameworks

In the past 2 years Massachusetts has made big changes in transportation infrastructure by tearing down toll booths along the I-90 Massachusetts Turnpike. Before October 28, 2016, 23 toll booths along 132 miles of highway created gated barriers to car travel. At these booths cars lined up to pay cash tolls or slowed down to pass through gates using an E-Z Pass transponder. With the new “open-road tolling” there are no toll booths and cars stream along beneath metal gantries that capture transponder data or license plate pictures. Not only is traffic moving smoothly, but electronic tolling generates a wealth of data about traffic speed and patterns.

Despite progress in health IT, Health Information Exchange (HIE) remains squarely in toll booth mode, with gated stops and slowdowns that may or may not permit information to move forward. According to the Office of the National Coordinator for Health IT (ONCHIT), in the U.S. there are more than 100 regional HIEs. Providers and health organizations often join multiple HIEs to gather data on individual patients and patient populations. A recent survey of 70 hospitals revealed that the majority used more than 3 HIE methods and 30% of the hospitals had at least 5 HIE methods all requiring multiple contractual agreements and IT solutions. HIE is often stuck at the toll booth.

HIE and the ONC TEFCA directive

The 21^st Century Cures Act passed by congress in December 2016 included sections of the law supporting progress in HIE. Section 4003 includes a specific directive to ONC to “…develop or support a trusted exchange framework, including a common agreement among health information networks nationally.” The 21^st Century Cures Act requires ONC to act to establish interoperability. Over the past year ONC has completed stakeholder diligence, and on January 5, 2018, published a Trusted Exchange Framework and Common Agreement (TEFCA) draft document. This may be the start of seamless HIT data exchange—no stopping, no gateways, no barriers to exchanging health data.

The ONC TEFCA document targets 4 key outcomes:

• Providers will be able to access patient records from any place the patient presents to receive care
• Patients will have easy access to their health data
• Providers and payers who are responsible for the health of a patient population can get aggregated data without having to access 1 patient record at a time
• HIT will support application programming interfaces (APIs) to enhance EHR usability and improve access to health information

One option for creating seamless HIT access to data is a single Nationwide Health Information Network (NHIN). The health information network (HIN) would connect all providers to enable access to, use of, and exchange of health data. A single NHIN model has been discarded since it fails to have the flexibility to meet the needs of all provider stakeholders. Instead the TEFCA proposes a “single on-ramp” model with policies, procedures, and technical standards to connect multiple HINs regardless of EHR vendors or HIE networks.

Trusted Exchange and Common Agreements

The ONC TEFCA plan has 2 parts. Part A includes the “principles for trusted exchange” and Part B outlines the “minimum required terms and conditions for trusted exchange.” Both parts are incorporated in a Common Agreement.

The 6 principles of TEFCA Part A include:

1. Standardization of data
   1. Use of Consolidated Clinical Data Architecture (C-CDA)
   2. Avoid proprietary standards that inhibit data sharing
   3. Use of 2015 Edition HIT certified EHRs standards for data exchange
2. Exchange transparency
   1. Qualified HINs (QHIN is an HIN that has agreed to the terms set forth in the Common Agreement) should voluntarily make contracts for HIT exchange publicly available
   2. QHINS should plan to exchange data for multiple HIPAA-permitted purposes, including clinical and financial purposes
3. Cooperation and non-discrimination
   1. QHINS should not withhold data exchange from providers or health plans that are competitors or are outside a preferred referral network
4. Privacy and security
   1. Data integrity must be ensured throughout the exchange process
   2. Patient safety is paramount, beginning with correctly matching individuals across systems to insure care is provided to the right individual based on the right information
   3. Meet HIPAA consent requirements for exchange of some health information such as disclosure of mental health and addiction treatments
5. Easy access
   1. Ensure that there are no unnecessary barriers to patient access to their own health information
   2. Patient access should be “easy and convenient”
   3. Enable patients to request data to be sent to a third party of their choosing
6. Data-driven accountability
   1. The system should support the exchange of population-based data as a cohort and not 1 patient record at a time

TEFCA Part B outlines minimum required terms and conditions of the Common Agreement for the QHINs. As a governance document for QHINs to ensure common practices the Common Agreement will include:

• Rules to ensure a common authentication process for all HIN participants, including identity proofing to create a “trusted identity” for every user
• Common rules for trusted information exchange
• A minimum core set of policies regarding information exchange among HINs

Why should providers care about TEFCA?

If a Trusted Exchange Framework is established, providers will have an open-road connection to multiple entities who can share patient information. Data will flow among physician practices, hospitals, long-term care facilities, behavioral health entities, and social service organizations. Providers will not have to negotiate or wait for connections one by one or access data in multiple systems, and data may be presented in a single user interface. HIPAA compliance and the assured authentication of right patient to right provider will be an integral part of the system. Proprietary entities will be prohibited from slowing down or preventing access to data from competing entities. Access to more complete healthcare information will improve efficiency and continuity of care as well as care coordination and communication.

The last cash toll on the Massachusetts Turnpike was collected at 9:45 pm on October 28, 2016. At 10 pm construction crews began to tear down toll booths that had been traffic barriers since highway construction was completed in 1959. Open-road tolling has structure and cost, but no visible barriers. TEFCA can transition HIT to a much-needed safe, secure, yet open information highway.

Dugan Maddux, MD, FACP, is the Vice President for CKD Initiatives for FMC-NA. Before her foray into the business side of medicine, Dr. Maddux spent 18 years practicing nephrology in Danville, Virginia. During this time, she and her husband, Dr. Frank Maddux, developed a nephrology-focused Electronic Health Record. She and Frank also developed Voice Expeditions, which features the Nephrology Oral History project, a collection of interviews of the early dialysis pioneers.

Image from www.canstockphoto.com.