TEFCA went live at the end of December 2023 with a roster of five Qualified Health Information Networks and a promise to become the backbone of nationwide health data exchange. Roughly a year and a half later, that promise is only partly fulfilled. The QHIN list has grown, real patient records are moving across it every day, and a formal FHIR roadmap is finally taking shape. At the same time, providers and health systems are still asking a blunt question: does TEFCA add enough value to justify running it alongside the private-sector networks — Carequality and CommonWell chief among them — that already move most of the country’s health data?

This is where things stand in 2025.

The QHIN roster has more than doubled

When the Trusted Exchange Framework and Common Agreement launched, only a handful of organizations had gone through the onboarding gauntlet required to become a Qualified Health Information Network: eHealth Exchange, Epic (as Epic Nexus), Health Gorilla, KONZA, and MedAllies were among the first cohort recognized at go-live.

Since then, the roster has grown steadily. CommonWell Health Alliance and Kno2 were designated in 2024, bringing established participant networks into TEFCA’s federal framework rather than leaving them to operate solely through private agreements. Through 2025, additional networks completed onboarding as well, including eClinicalWorks’ Prismanet network, Netsmart, Surescripts, and Oracle Health Information Network — each designation adding its underlying base of hospitals, clinics, and ambulatory practices to TEFCA’s reach. The Sequoia Project, which operates as the Recognized Coordinating Entity (RCE) under contract with the Assistant Secretary for Technology Policy (ASTP, formerly ONC), maintains the current list of Designated QHINs and a separate list of Candidate QHINs still in the onboarding pipeline.

That growth matters less as a count than as a signal: the QHIN application process is open on a rolling basis, and vendors with large existing installed bases — EHR platforms and established HIEs alike — have concluded that QHIN status is worth the compliance investment. Each new QHIN theoretically extends TEFCA’s reach without requiring every downstream participant and subparticipant to sign a fresh set of bilateral agreements, which is the structural bet TEFCA was designed around: one common legal and technical agreement instead of a patchwork of point-to-point contracts.

It’s worth noting that QHIN counts and designation dates are still in motion. Readers checking current numbers should treat any specific figure as a snapshot and confirm against the RCE’s own designated-QHIN listing, since new organizations continue to move through the pipeline.

Exchange volume is real, but purpose mix still skews narrow

TEFCA supports six exchange purposes: treatment, payment, healthcare operations, public health, government benefits determination, and individual access services. In practice, adoption has not been evenly distributed across all six.

Treatment-purpose queries — a provider looking up a patient’s outside records at the point of care — remain the dominant use case, largely because that’s the exchange purpose most participants were already doing informally through Carequality or CommonWell and is the easiest to map onto existing clinical workflows. Public health exchange has also gained traction, particularly for reporting use cases that state and federal agencies were already prioritizing.

Individual access services (IAS) — the purpose that lets patients or their authorized apps pull their own records through TEFCA, functioning as an alternative to logging into a separate portal for every provider — has been slower to mature operationally, even though it is arguably the purpose most visible to patients themselves. Standard operating procedures governing how IAS should be implemented, including patient identity verification and matching, were still being refined and commented on well into 2025, which tells you the policy groundwork was still catching up to the technical capability.

Government benefits determination is the newest addition to the purpose list, aimed at helping agencies verify eligibility for programs without requiring applicants to manually track down and submit their own medical records. Because it touches non-clinical government workflows, it’s a genuinely new use case for the framework rather than a formalization of something the private networks already did.

The overall trend is upward — more organizations live, more connections established, more queries flowing — but the purpose mix in 2025 still looks more like “treatment exchange with public health and payer use cases catching up” than the full six-purpose vision TEFCA was chartered to deliver.

The FHIR roadmap is moving from paper to pilots

TEFCA’s original technical backbone leans on IHE-based document exchange protocols — the same approach that underpins Carequality and CommonWell. But the industry’s momentum, especially post-Cures Act API mandates, is toward FHIR-based data access. ASTP and the RCE addressed that gap with the FHIR Roadmap for TEFCA Exchange, now in its second version, which lays out four progressive stages:

  1. FHIR content support — QHINs can broker FHIR-formatted payloads over the existing IHE transport, without a standardized FHIR API layer.
  2. QHIN-facilitated FHIR exchange — QHINs begin enabling FHIR API queries between their own participants using shared directory and record-location services.
  3. QHIN-to-QHIN FHIR exchange — QHINs use FHIR APIs to exchange data directly with each other, supplementing (not yet replacing) the document-based exchange running underneath.
  4. End-to-end FHIR exchange — Full FHIR-based routing across QHINs and down to participants and subparticipants, the eventual target state.

As of 2025, TEFCA sits mostly in stage one, with the RCE and QHINs working toward piloting QHIN-to-QHIN FHIR exchange within the year — a meaningful step toward stage three, though still short of an operational default. The expectation communicated by the RCE is that pilot results would inform updated technical framework specifications, with broader infrastructure deployment by QHINs following in subsequent years rather than an immediate network-wide switch.

The practical implication for health IT teams: FHIR-based TEFCA exchange is a real, funded roadmap item, not a hypothetical, but organizations budgeting for it in the near term should plan around pilots and incremental capability rather than a single cutover date.

The open question: does TEFCA add value, or just add overhead?

The most persistent skepticism about TEFCA in 2025 isn’t about whether it works technically — QHINs are exchanging real records — it’s about whether it’s additive. Carequality and CommonWell were already moving hundreds of millions of document exchanges annually before TEFCA existed, largely for the same treatment-purpose use case that dominates TEFCA volume today. For a hospital or health system already connected to one or both of those networks, the immediate question is what TEFCA gets them that they don’t already have.

Carequality’s own public position has been to “thoughtfully align” its policies with TEFCA rather than compete with it outright, and organizations like CommonWell have pursued QHIN designation themselves — effectively becoming a bridge that lets their existing participant base reach TEFCA without a separate onboarding process. That path reduces duplicate plumbing, but it also means a meaningful share of what shows up in TEFCA’s growing connection counts is capacity that already existed under a different name, now routed through an additional legal and governance layer.

Supporters argue that federal backing, a single common agreement, and defined exchange purposes beyond treatment (particularly government benefits determination and individual access) are precisely the things a purely voluntary private network was never going to standardize on its own — and that overlap during a transition period is the expected cost of consolidating a fragmented interoperability landscape into one framework. Skeptics counter that until FHIR-based exchange, individual access services, and cross-network deduplication mature, health systems are effectively maintaining connections to overlapping networks that solve the same treatment-exchange problem twice.

Neither view is fully settled, and the answer will likely differ by organization: a system with no existing Carequality or CommonWell connectivity gets much clearer incremental value from joining TEFCA than one that already has mature exchange relationships and is weighing whether a QHIN connection duplicates work it’s already done.

What to watch through the rest of 2025

A few threads are likely to determine whether TEFCA’s second full year looks meaningfully different from its first:

  • Whether QHIN-to-QHIN FHIR pilots produce usable implementation specifications, or slip into 2026 as a planning exercise.
  • Whether individual access services SOPs settle on identity-verification and patient-matching approaches that both app developers and provider organizations — some of which have raised privacy and verification concerns — are comfortable implementing.
  • Whether government benefits determination exchange sees real agency adoption, which would be the clearest evidence TEFCA is expanding use cases rather than just re-routing existing treatment-purpose volume.
  • Whether additional QHIN designations continue at the current pace, or whether the pipeline of credible new applicants is thinning as most large networks that wanted in have already joined.

For more background on how TEFCA’s governance and QHIN model work, see HealthIT.gov’s TEFCA program page, maintained by the Assistant Secretary for Technology Policy.

This article is for general informational purposes and does not constitute legal, compliance, or medical advice. Organizations evaluating TEFCA participation should consult current guidance from the Sequoia Project (as Recognized Coordinating Entity) and ASTP/HealthIT.gov directly, since QHIN designations, SOPs, and exchange-purpose rules continue to evolve.

Frequently Asked Questions

What is a QHIN under TEFCA?

A Qualified Health Information Network (QHIN) is an organization that has completed onboarding and signed the Common Agreement to exchange data under TEFCA on behalf of its own network of participants and subparticipants, such as health systems, HIEs, and EHR platforms.

How many QHINs are designated in 2025?

The number has grown steadily since TEFCA’s late-2023 launch, from an initial handful to more than double that by 2025, with additional organizations in the onboarding pipeline. Because designations continue on a rolling basis, current counts should be checked against the RCE’s official list rather than treated as fixed.

Is TEFCA replacing Carequality and CommonWell?

Not directly. CommonWell became a QHIN itself, and Carequality has said it intends to align its policies with TEFCA rather than compete with it. In practice, the networks currently coexist, with meaningful overlap in the treatment-purpose exchange each already supported.

When will TEFCA support FHIR-based data exchange?

TEFCA’s FHIR roadmap defines four stages, moving from FHIR content carried over existing document-exchange protocols toward full FHIR-based routing. As of 2025, QHIN-to-QHIN FHIR exchange pilots were getting underway, with broader deployment expected in later years rather than immediately.

What is individual access services (IAS) under TEFCA?

IAS is the TEFCA exchange purpose that lets patients, or apps acting on their behalf, retrieve their own health records directly through the network, similar to a patient portal but not tied to a single provider’s system. Implementation rules for identity verification and matching were still being finalized in 2025.