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Nation’s clinical informatics professionals support Draft 2 of TEFCA, while recommending modifications to improve stakeholder participation

(BETHESDA, MD) — In comments submitted to the Office of the National Coordinator for Health Information Technology (ONC), the American Medical Informatics Association (AMIA) largely supported several key changes in the Trusted Exchange Framework and Common Agreement (TEFCA) Draft 2. However, the group reiterated its initial call for a detailed implementation plan and strongly recommended that ONC develop such a roadmap alongside the eventual Recognized Coordinating Entity (RCE) and other stakeholders as part of the policy’s next iteration.

ONC issued a second draft of the TEFCA and issued a contract for the TEFCA’s Recognized Coordinating Entity (RCE) in April. The TEFCA was first proposed in January 2018, aiming to (1) provide a single “on-ramp” for providers to connect with other providers nationwide; (2) ensure electronic information securely follows patients when and where it is needed; and (3) support nationwide scalability for network connectivity.

AMIA supported these goals and recommended ONC proceed with several key changes in Draft 2. Specifically, AMIA supported new prerequisites for Qualified Health Information Networks (QHINs) and the establishment of Minimum Required Terms and Conditions (MRTCs) and the QHIN Technical Framework (QTF). AMIA also supported updates to Exchange Purposes and Exchange Modalities sections, with some modification, as long as an implementation plan was developed to articulate subsequent TEFCA phases.
“This roadmap should include specific milestones and points of engagement, as well as describe (1) what will be required of TEFCA stakeholders for the initial phase; (2) generally, what is being considered for inclusion in a subsequent phase; and (3) what accountability mechanisms will be in place to garner feedback and input,” AMIA’s comments said. “It will only be through engagement, accountability, and transparency that this ‘network of networks,’ will successfully emerge and evolve.”

The Exchange Purposes section of Draft 2 requires exchange for a subset of activities in Payment (Utilization Review) and Health Care Operations (Quality Assessment and Improvement, and Business Planning and Development) as defined in the HIPAA Privacy Rule. While AMIA considered this an improvement, it was still concerned that it is too broad for the initial phase of the TEF, especially the purpose of Business Planning and Development. It thus recommended that ONC and the RCE consider permitted purposes beyond treatment and individual access in a subsequent phase of the TEF.

AMIA also supported the Draft 2 Exchange Modalities, along with Draft 2’s inclusion of push message delivery to query. Nonetheless, it cautioned that various technical specifications to support those modalities are still immature and various technical specifications meant to support these modalities are either under-developed or in a state of flux.
Finally, AMIA applauded ONC’s recognition that non-HIPAA entities are growing in significance to individuals’ health and are fast becoming important parts of the care continuum. “We fully support ONC’s policy that requires non-HIPAA entities, who elect to participate in exchange, to be bound by certain provisions that align with safeguards of the HIPAA Rules,” AMIA noted in comments.

“Just as we did with stages of Meaningful Use, we must walk before we can run.” said AMIA President and CEO Douglas B. Fridsma, MD, PhD, FACP, FACMI. “ONC must establish baseline capabilities and achievable requirements to enable broad participation in TEFCA. After we gain experience, ONC can work with the RCE and other stakeholders to phase in new requirements, improved standards, and additional capabilities.”

Click here for AMIA’s full response to the TEFCA Draft 2.


AMIA, the leading professional association for informatics professionals, is the center of action for 5,500 informatics professionals from more than 65 countries. As the voice of the nation’s top biomedical and health informatics professionals, AMIA and its members play a leading role in assessing the effect of health innovations on health policy, and advancing the field of informatics. AMIA actively supports five domains in informatics: translational bioinformatics, clinical research informatics, clinical informatics, consumer health informatics, and public health informatics.