Consider this scenario: Dr. Garcia who practices in Texas has given an immunization to a child who will soon move to Virginia. Dr. Garcia is able to send the immunization record to Virginia’s Immunization Information System (IIS) through a chain of health information networks (HINs). This information “push” happens automatically, sending an individual’s immunization record to the appropriate jurisdiction’s IIS, every time Dr. Garcia records an immunization in her electronic record system. Gone are the days where electronic health record systems and health information networks do not talk to each other. There is no more need for unique point-to-point electronic connections, each with their own governance agreements and costly automated interfaces. Trusted health information exchange has been simplified and standardized so that local HINs across the country are able to connect and share information through a single “on-ramp” for connectivity. Now, health information exchange is able to scale nationwide.
We are almost there. In 2016, Congress passed the 21st Century Cures Act which directs the federal Department of Health and Human Services, Office of the National Coordinator for Health Information Technology (ONC) to scale health information exchange to a nationwide level by developing a trusted exchange framework and a common agreement. This is known as TEFCA (Trusted Exchange Framework and Common Agreement).
The time is now for public health to understand TEFCA and its many opportunities to improve public health functions. TEFCA will connect public health, government agencies, individuals, providers, payers and technology developers. A significant benefit to everyone participating in the TEFCA is that electronic health information securely follows you when and where it is needed, across the country.
The Trusted Exchange Framework (TEF) facilitates trust among the participating HINs by ensuring adherence to the following principles:
Principle 1 – Standardization: Adhere to industry and federally recognized standards, policies, best practices, and procedures [for health information exchange].
Principle 2 – Transparency: Conduct all exchange and operations openly and transparently.
Principle 3 – Cooperation and Non-Discrimination: Collaborate with stakeholders across the continuum of care to exchange [electronic health information (EHI)], even when a stakeholder may be a business competitor.
Principle 4 – Privacy, Security, and Safety: Exchange EHI securely and in a manner that promotes patient safety, ensures data integrity, and adheres to privacy policies.
Principle 5 – Access: Ensure that individuals and their authorized caregivers have easy access to their EHI.
Principle 6 – Population-Level Data: Exchange multiple records for a cohort of individuals at one time in accordance with applicable law to enable identification and trending of data to lower the cost of care and improve the health of the population.
The Common Agreement provides the governance to scale the system of networks to cover the entire country and address needed changes to appropriately meet stakeholder requests. The Common Agreement provides the rules that the HINs will abide by so that operations run smoothly, legal requirements are met and functional and technical requirements are satisfied. The Recognized Coordinating Entity (RCE) will provide oversight and governance for the participating HINs.
Earlier this year, in the second draft of proposed TEFCA regulations, ONC identified public health as one of the exchange purposes for this new nationwide system of networks. Other purposes include treatment, quality improvement and patient access. Leveraging the TEFCA will position public health to work faster and more efficiently towards health equity through electronic case reporting; immunization reporting and cross-jurisdictional immunization exchange; syndromic surveillance, electronic lab reporting and cancer registry reporting; patient tracking and family reunification during emergencies; identification of at-risk populations; and disease surveillance and outbreak investigation.
In response to the proposed TEFCA regulations, the public health community voiced its support for the addition of “push” data exchange which is essential to public health reporting. Because public health is a critical component of the nation’s health infrastructure, commenters to the proposed TEFCA regulation stated that TEFCA should make clear that public health is represented in the governance of the RCE. Further, commenters identified that public health has legal requirements and needs that differ from health care providers who are not part of government and who may not be focused on population health, and that these differences must be addressed. Importantly, commenters requested that the language in TEFCA that releases federal agencies from HIPAA compliance where they are not otherwise subject to HIPAA, be extended to state and local government public health agencies.
ONC plans to identify and award the RCE contract in August/September 2019 and release the first draft of the Common Agreement in 2020.
Along with the benefits, public health will need to be prepared to undertake certain responsibilities and obligations. For example, public health will need to join a HIN that is connected to the network created by the Common Agreement, which we’ll call the TEF Network. Strategically, public health and its jurisdiction’s government need to begin planning how to facilitate data sharing through the TEF Network, such as by requiring Medicaid managed care contracts require providers to connect to the TEF Network for data sharing. Additionally, ONC recommends that jurisdictions also include the Common Agreement in regulatory requirements that address HINs.
This post was written by Sallie Milam, JD, CIPP/US/G, Deputy Director, Network for Public Health Law – Mid-States Region Office.
The Network for Public Health Law provides information and technical assistance on issues related to public health. The legal information and assistance provided in this document do not constitute legal advice or legal representation. For legal advice, readers should consult a lawyer in their state.
Support for the Network is provided by the Robert Wood Johnson Foundation (RWJF). The views expressed in this post do not necessarily represent the views of, and should not be attributed to, RWJF.