For nearly two years, the Trusted Exchange Framework and Common Agreement existed mostly on paper — a finished rulebook waiting for someone to actually operate under it. That changed this week. On December 12, 2023, the Office of the National Coordinator for Health Information Technology (ONC) and The Sequoia Project, acting as the Recognized Coordinating Entity (RCE), designated the first Qualified Health Information Networks, or QHINs, under TEFCA. The designation happened at a Common Agreement signing event in Washington, D.C., with HHS Secretary Xavier Becerra, HHS Deputy Secretary Andrea Palm, and National Coordinator Micky Tripathi in attendance — a level of ceremony that signals how long the industry has been waiting for this specific milestone.

This is the moment TEFCA shifts from framework to functioning network, at least in its earliest form. Here’s who was designated, what QHIN status actually means, and — just as important — what hasn’t changed yet.

What Happened on December 12

The Sequoia Project, under its role as RCE for ONC, announced that five organizations completed the QHIN application, onboarding, and technical testing process and signed the Common Agreement, formally becoming the country’s first designated QHINs. According to coverage of the announcement, the organizations reportedly moved through the qualification process in under a year, a pace regulators had pushed for since HHS Secretary Becerra set an aggressive timeline for launch earlier in 2023.

Mariann Yeager, CEO of The Sequoia Project, was quoted describing the vetting process as intentionally demanding: the QHIN selection and onboarding process was designed to be rigorous, she said, to ensure the organizations designated first were prepared to serve as the backbone for nationwide health information exchange. That framing matters. TEFCA’s entire premise rests on trust — the idea that a query from one participant can be trusted by every other participant in the network without a separate one-off legal agreement. A shaky first cohort would undermine that premise before it had a chance to prove itself.

The First QHINs

Based on the ONC and Sequoia Project announcement, the initial group of designated QHINs is reported to include:

  • eHealth Exchange
  • Epic Nexus
  • Health Gorilla
  • KONZA National Network
  • MedAllies

Each of these organizations operated some form of health information exchange network prior to TEFCA — this wasn’t a group of brand-new entrants building infrastructure from scratch. eHealth Exchange, for instance, has functioned as one of the country’s largest existing health data exchange networks for years, connecting federal agencies, health systems, and other participants. Epic Nexus is tied to the exchange capabilities Epic has built into its widely used EHR platform. What’s new isn’t that these networks move health data — it’s that they’ve now formally qualified to do so under a single common set of technical standards and legal terms, rather than each maintaining its own separate web of bilateral agreements with other networks.

It’s worth flagging that QHIN designation is not static. The Sequoia Project has indicated additional candidate organizations are moving through the onboarding pipeline, so the roster of designated QHINs should be expected to grow over time. Readers should treat any list as a snapshot of this specific announcement rather than a permanently fixed set.

What QHIN Designation Actually Means

A QHIN is not a hospital, a clinic, or an individual health information exchange (HIE). It’s an organization — typically one already operating a health information network — that has gone through the RCE’s formal designation process and signed the Common Agreement, the legal contract at the center of TEFCA. Designation means the organization has demonstrated it meets the technical specifications in the QHIN Technical Framework and has agreed to the privacy, security, and permitted-use obligations the Common Agreement spells out.

The design goal behind TEFCA is a “network of networks.” Rather than every hospital, health system, or regional HIE needing its own direct technical connection and legal agreement with every other network it wants to exchange data with, each participant connects through a QHIN. That QHIN, in turn, connects to other QHINs. In theory, once a health system’s network is reachable through a single QHIN, a query it sends can extend to every other participant reachable through any other designated QHIN — collapsing what has historically been a tangle of point-to-point connections into a smaller number of standardized handoffs.

Exchange Purposes: What Data Can Move, and Why

TEFCA doesn’t permit unrestricted data sharing. Every query exchanged through the network has to be tied to a permitted “exchange purpose” defined in the Common Agreement. The framework’s exchange purposes are reported to include treatment, individual access services (allowing patients to request their own records), public health, benefits determination, payment, and health care operations.

In practice, treatment-related queries are expected to be the most immediate use case as the network comes online — a provider looking up a patient’s records from another network at the point of care is the scenario TEFCA’s backers most often cite when explaining why the framework exists. Public health reporting and individual patient access to records are also cited as priority purposes, though how quickly each purpose sees real usage will depend on which participants connect through which QHINs and how quickly workflows on both ends are built to actually use the new pathways.

What Changes — and What Doesn’t, Yet

It’s tempting to read “QHINs are designated” as “nationwide health data exchange is now live and complete.” That’s not quite accurate, at least not yet.

What has changed: there is now, for the first time, a legally and technically defined path for health information networks to exchange data under one common national framework instead of a patchwork of separate agreements. Five organizations have committed to that framework and met its technical bar. According to reporting on the launch, participants began exchanging data within days of the signing event — an early, real-world test of the plumbing.

What hasn’t changed, at least not immediately: designation of a QHIN doesn’t mean every hospital, clinic, or health system in the country is suddenly connected to TEFCA. Provider organizations still need to connect through a participating QHIN or one of its participants, and many existing regional and vendor networks have not yet gone through that process. The practical reach of TEFCA on day one is a function of which networks — and which of their existing customers or members — are actually reachable through the five newly designated QHINs, not the entire U.S. health system at once. Expanding that reach, refining the technical framework, and onboarding additional QHINs are explicitly described as ongoing work by both ONC and the Sequoia Project, not a one-time event that concluded on December 12.

Why This Milestone Matters

TEFCA’s legal roots go back to the 21st Century Cures Act of 2016, which directed ONC to develop a trusted exchange framework and a common agreement among health information networks. The Common Agreement itself wasn’t published until January 2022. Getting from a published rulebook to actual designated participants took roughly two more years — a timeline that reflects how much technical and legal groundwork sits underneath what sounds, on the surface, like a simple certification.

For health IT leaders, the significance of this week’s announcement — detailed in The Sequoia Project’s designation notice — is less about any single QHIN and more about proof of concept: the designation process works, organizations can complete it, and data can move under the resulting agreement. Whether TEFCA fulfills its ambition of functioning as true nationwide plumbing for health data will depend on how many more networks pursue designation, how quickly existing HIEs and health systems connect through the QHINs now live, and how exchange volume grows from this initial baseline.

Frequently Asked Questions

What is a QHIN?

A Qualified Health Information Network is an organization — usually one already operating a health information network — that has completed The Sequoia Project’s designation process and signed the TEFCA Common Agreement. QHINs serve as connection points so participants reach the broader network through a single relationship rather than separate agreements with every other network.

How many QHINs were designated in December 2023?

Reporting on the December 12, 2023 announcement identifies five organizations as the first designated QHINs: eHealth Exchange, Epic Nexus, Health Gorilla, KONZA National Network, and MedAllies. Additional organizations were reported to be in the onboarding pipeline at the time of designation.

Does QHIN designation mean my hospital is now connected to TEFCA?

Not automatically. A hospital or health system is connected only if it participates in a network that has itself joined a designated QHIN. Provider organizations working with a network that hasn’t yet completed the QHIN process, or that hasn’t joined one, are not yet reachable through TEFCA.

What can data be exchanged for under TEFCA?

The Common Agreement limits exchange to defined “exchange purposes,” reported to include treatment, individual access to one’s own records, public health, benefits determination, payment, and health care operations. Every query moving through the network is expected to be tied to one of these permitted purposes.

Is TEFCA the same as a QHIN?

No. TEFCA is the overall framework — the Trusted Exchange Framework and the Common Agreement — that establishes the rules, technical standards, and legal terms for exchange. A QHIN is an individual organization that has been designated to operate under that framework. TEFCA is the rulebook; QHINs are the entities that have qualified to play by it.