Ask five health IT professionals what “interoperability” means in practice and you’ll likely get five different answers involving five different networks, five different sets of legal agreements, and five different technical specifications. That fragmentation is precisely the problem the Trusted Exchange Framework and Common Agreement — known throughout the industry as TEFCA — was built to address.

TEFCA is not a single piece of software or a new pipe that data flows through. It’s a governance structure: a common set of rules, technical standards, and legal terms that existing health information networks can adopt so that a query originating in one network can reliably reach and retrieve data from another. The federal government published the first version of the Common Agreement in January 2022, marking a milestone years in the making. But TEFCA is best understood as infrastructure that is still being assembled — the rulebook exists, and the organizations that will operate under it are still working through the process of qualifying to do so.

This article walks through what TEFCA is, where it came from, what a QHIN is meant to be, who is coordinating the effort, and how the framework relates to health information networks that already move clinical data today.

Where TEFCA Came From

TEFCA traces its legal origin to the 21st Century Cures Act, the sweeping health policy law enacted in December 2016. Section 4003(b) of the Cures Act directed the Office of the National Coordinator for Health Information Technology (ONC) to “develop or support a trusted exchange framework, including a common agreement among health information networks nationally.” Congress recognized that the country’s health information exchange landscape had grown into a patchwork of regional and vendor-specific networks, many of which had no formal way to talk to one another. Rather than mandate a single national network, lawmakers directed ONC to create a framework other networks could plug into voluntarily.

ONC spent the years following the Cures Act’s passage soliciting public comment, publishing draft frameworks, and revising its approach based on stakeholder feedback from health systems, health information exchanges (HIEs), technology vendors, and patient advocacy groups. In 2019, ONC designated the Sequoia Project, a nonprofit interoperability organization, as the Recognized Coordinating Entity (RCE) responsible for operationalizing the framework. That designation set the stage for the document that would actually put TEFCA into motion: the Common Agreement.

The Common Agreement v1: Published January 2022

On January 19, 2022, ONC and the Sequoia Project published the first version of the Trusted Exchange Framework, the Common Agreement, and the accompanying QHIN Technical Framework — collectively referred to as TEFCA. The publication was announced via a notice in the Federal Register and represented the first time the industry could review the actual contractual and technical terms it would eventually be asked to sign onto.

The Common Agreement functions as the legal backbone of TEFCA. It’s structured as a contract that health information networks sign in order to participate, and it establishes baseline obligations around privacy, security, individual access to records, and the permitted purposes for which data can be exchanged. The Trusted Exchange Framework itself is a separate, non-binding set of principles intended to guide how networks should behave even where the Common Agreement doesn’t specify exact technical requirements. Together with the QHIN Technical Framework — which lays out the technical specifications networks must implement to exchange data under TEFCA — these documents make up the full TEFCA package.

Publication of the Common Agreement did not mean TEFCA was immediately operational. It meant, instead, that the rulebook was finished and that organizations interested in participating could begin the formal process of applying to do so. That process, as outlined by the RCE, involves a multi-stage application, onboarding, and technical testing sequence that the Sequoia Project has estimated can take roughly a year to complete for a given applicant.

What a QHIN Is Supposed to Be

At the center of TEFCA’s design is a category of organization called a Qualified Health Information Network, or QHIN. A QHIN is not a hospital, a health system, or an individual HIE — it’s expected to be a health information network (or an organization operating one) that has gone through the RCE’s designation process, signed the Common Agreement, and met the technical requirements in the QHIN Technical Framework.

Under the model TEFCA is establishing, QHINs are meant to function as the connective layer of a “network of networks.” Individual health systems, HIEs, and health information networks would connect to TEFCA not directly, but through a QHIN, which would in turn connect to other QHINs. A hospital in one state would query its own network, which routes the query to its QHIN, which then routes it to the QHIN serving the network where a patient’s other records reside. In principle, this means a single connection into TEFCA is intended to open the door to every other participant reachable through any QHIN — a dramatically simpler model than the current reality, where a health system might need separate technical connections and legal agreements for each network it wants to exchange with.

As of this writing, no organizations have yet completed the designation process and been formally recognized as QHINs. The RCE has indicated that a number of established health information networks have expressed interest in pursuing designation, but formal QHIN status is a forward-looking milestone tied to completion of onboarding and testing under the newly published Common Agreement — not something that exists yet. Organizations and health systems evaluating TEFCA today are, in effect, evaluating a framework whose operational network layer is still being built out.

The RCE: The Sequoia Project’s Role

The Recognized Coordinating Entity is the organization ONC contracted with to develop, implement, and maintain TEFCA on an ongoing basis. The Sequoia Project, a Virginia-based nonprofit with a long history in health information exchange governance — it previously stewarded the Carequality interoperability framework and the eHealth Exchange network’s governance functions — was selected for this role in 2019 following a competitive process.

As RCE, the Sequoia Project is responsible for a range of functions that keep TEFCA running day to day: publishing and updating the Common Agreement and its associated Standard Operating Procedures (SOPs), reviewing and approving QHIN applications, maintaining a directory intended to let QHINs locate and validate one another, and serving as the primary point of contact between ONC and the organizations seeking to participate in TEFCA. The RCE does not itself move patient data; its role is governance and coordination, not operation of the exchange infrastructure. That distinction matters — the RCE sets and enforces the rules, while QHINs and their participants are the ones actually exchanging information once the network layer is live.

How TEFCA Relates to Carequality and eHealth Exchange

One of the most common questions about TEFCA is how it relates to the health information networks that already exist and already move real clinical data — chief among them Carequality and eHealth Exchange, both of which the Sequoia Project has also been closely involved with historically.

Carequality is a framework, not a network operator itself: it establishes common legal and technical terms that let separate networks (including major EHR vendor networks) exchange data under a shared trust framework, without needing bilateral agreements between every pair of participants. eHealth Exchange is one of the longest-running health information networks in the country, connecting federal agencies, health systems, and HIEs. Both predate TEFCA by years and both currently facilitate large volumes of real-world clinical document exchange.

TEFCA is not designed to replace these networks. Instead, it’s intended to sit alongside them as a higher-level, federally backed framework that existing networks — including Carequality and eHealth Exchange — can align with or connect through, potentially by pursuing QHIN designation themselves or by having a participating QHIN represent their network’s members. Organizations that already exchange data through Carequality or eHealth Exchange are not expected to lose that connectivity; rather, TEFCA aims to add a nationwide governance layer with a single legal agreement and set of technical standards, reducing the need for networks to maintain separate agreements for every network they want to reach.

Because QHINs have not yet been designated, exactly how existing networks will map onto the TEFCA model in practice is still developing. ONC and the RCE have said they expect a mix of participation approaches, including some existing networks pursuing QHIN status directly. Health IT leaders evaluating their organization’s exchange strategy should watch this space closely, since the eventual designation of QHINs will determine which paths into TEFCA are available and how they interact with connections organizations already have in place.

What This Means for Health IT Leaders Right Now

For hospital IT departments, HIE operators, and health information network leaders, TEFCA in its current form is a framework to plan around rather than a network to join today. The Common Agreement’s publication in January 2022 gave the industry its first complete look at the legal and technical terms of participation, which is valuable for planning purposes even before any organization holds QHIN status. Organizations that already participate in Carequality, eHealth Exchange, or a state or regional HIE should continue relying on those existing connections for current interoperability needs, while tracking how those networks position themselves relative to TEFCA and the QHIN designation process going forward.

The most productive posture for most organizations at this stage is informed patience: understand the Common Agreement’s requirements, watch which networks pursue QHIN designation, and factor TEFCA into long-term interoperability roadmaps without assuming its network-of-networks model is available to use immediately.

For the authoritative source documents, including the full text of the Common Agreement, the Trusted Exchange Framework, and the QHIN Technical Framework, see ONC’s TEFCA resource page.

This article is for general informational purposes only and does not constitute legal, regulatory, or compliance advice. Organizations should consult ONC’s official TEFCA documentation and their own legal counsel before making participation or implementation decisions.

Frequently Asked Questions

What is TEFCA in simple terms?

TEFCA is a federally supported framework — a set of legal terms and technical standards — meant to let health information networks exchange patient data nationwide under one common agreement, rather than each network needing separate bilateral agreements with every other network it wants to connect to.

Is TEFCA a new health information network?

No. TEFCA doesn’t operate its own network or move data itself. It’s a governance framework that existing and future health information networks can adopt, letting them exchange data with each other under shared legal and technical rules established by ONC and the RCE.

What is a QHIN?

A QHIN, or Qualified Health Information Network, is a health information network expected to be formally designated after completing an application, onboarding, and technical testing process, then signing the Common Agreement. QHINs are intended to serve as the connective backbone linking other networks under TEFCA.

Who manages TEFCA day to day?

The Sequoia Project, a nonprofit interoperability organization, serves as the Recognized Coordinating Entity (RCE) under contract with ONC. The RCE develops and maintains the Common Agreement, reviews QHIN applications, and coordinates the framework’s ongoing operation.

Does TEFCA replace networks like Carequality or eHealth Exchange?

No. TEFCA is designed to complement rather than replace existing networks. Organizations already connected through Carequality, eHealth Exchange, or regional HIEs are expected to retain that connectivity, with TEFCA intended to add a nationwide layer those networks can align with over time.