By Eric Andrew Kristof, RN, CAHIMS | Healthcare IT Professional | HIMSS Arkansas Chapter Member
About This Series: The HIMSS Word of the Day is a running blog series drawing from the HIMSS Dictionary of Health Information and Technology Terms, Acronyms, and Organizations, 6th Edition (2025) — the authoritative reference for healthcare IT professionals and the primary study resource for CAHIMS and CPHIMS certification. Each post paraphrases the term in plain language, grounds it in real-world healthcare IT context, and adds a bedside nursing perspective you won’t find in a textbook.
📖 The Term: Trusted Exchange Framework and Common Agreement (TEFCA)
Source: HIMSS Dictionary of Health Information and Technology Terms, Acronyms, and Organizations, 6th Edition (2025)
🔍 Plain-Language Definition
TEFCA is the federal framework that links separate health information networks into one national “network of networks,” with shared rules so that a hospital, clinic, health plan, or patient connected to one network can exchange information with organizations on another.
The HIMSS Dictionary traces TEFCA to the 21st Century Cures Act, in which Congress recognized the importance of interoperability and charged ONC with creating, or backing, a national framework for trusted exchange along with one agreement that health information networks nationwide could sign. The framework sets out shared principles and the minimum terms that participants must follow, with the aim of closing the gaps between the information systems used by different providers and patients. The dictionary notes the first draft of the framework appeared in January 2018; TEFCA has since become operational.
TEFCA has several moving parts:
| Component | What It Is |
|---|---|
| Trusted Exchange Framework | A set of non-binding principles for trusted exchange, such as transparency, cooperation, and privacy |
| Common Agreement | The binding legal agreement that networks sign to join TEFCA |
| Recognized Coordinating Entity (RCE) | The organization that manages TEFCA day to day; The Sequoia Project serves in this role under contract with ONC |
| Qualified Health Information Networks (QHINs) | The designated networks that form TEFCA’s backbone and connect to one another |
| Participants and Subparticipants | Organizations such as health systems, clinics, and HIEs that connect to TEFCA through a QHIN |
| QHIN Technical Framework | The technical specifications QHINs use to exchange data |
TEFCA defines the reasons data may be requested and shared, called Exchange Purposes: treatment, payment, health care operations, public health, government benefits determination, and individual access services.
⚠️ Exam Alert: TEFCA is a governance and legal framework for nationwide exchange. It is not a data standard (that role belongs to standards such as C-CDA and FHIR) and not a data set (that is USCDI). A QHIN is a network designated under TEFCA, while an HIE can be any organization or activity that exchanges health information. Participation in TEFCA is voluntary, and the Cures Act is the law that called for it.
🌐 Why It Matters: Real-World Healthcare IT Context
Before TEFCA, nationwide exchange depended on a patchwork of networks, each with its own agreements and technical rules. A health system might belong to one network while its referral partners used another, which left gaps exactly where patients moved between organizations.
TEFCA reached a major milestone in December 2023, when ONC announced that the first QHINs had been designated and health data began flowing among them within days. Because each QHIN agrees to the same Common Agreement and technical framework, an organization connected through one QHIN can reach organizations connected through another.
TEFCA does not replace existing exchange overnight. Regional and state HIEs, vendor networks, and long-standing national frameworks continue to carry much of the country’s traffic, and organizations decide for themselves whether and how to connect to TEFCA. For many health systems, the practical question is less “TEFCA or not” than which path reaches the partners their patients actually move between, and how to avoid paying for and maintaining redundant connections.
TEFCA’s exchange has largely relied on document-based exchange, and ONC and the RCE have laid out a roadmap toward FHIR-based exchange over time. The inclusion of individual access services also matters: it creates a path for patients to retrieve their own records across networks through apps that meet TEFCA’s requirements.
Persistent challenges in nationwide exchange:
- Patient matching across organizations without a national patient identifier
- Inconsistent data quality and coding at the source
- Variation in how organizations respond to queries for each exchange purpose
- Privacy concerns, particularly for sensitive information and individual access through apps
- Workflow integration, so exchanged data shows up where clinicians actually look
What TEFCA is designed to improve:
- A single set of rules that replaces dozens of separate point-to-point agreements
- Connectivity across networks that previously did not exchange with one another
- Defined exchange purposes that clarify when organizations should respond to requests
- A governed path for public health and benefits determination use cases
- A route for individuals to access their own information across the country
🏥 The Nurse’s Perspective: Clinical, Bedside, & Workflow
Nurses rarely hear the word TEFCA, but they feel its absence every time an outside record does not arrive.
At the Bedside
A patient transferred from a hospital two states away, a traveler who arrives in the emergency department, or a new admission from a clinic on a different network all depend on cross-network exchange. When it works, outside medication lists, allergies, problems, and recent results are available during admission. When it does not, nurses fall back on phone calls, faxes, and the patient’s memory.
TEFCA’s purpose is to make that first scenario normal, so that the network a patient’s previous provider happened to join no longer determines whether information follows the patient.
In Clinical Workflow
Exchanged records are only useful if they are reviewed. Outside documents can be long, duplicative, and arrive in a separate section of the chart. Nursing workflows for admission reconciliation, transfer acceptance, and discharge planning need clear steps for finding and reconciling outside data, not just access to it.
Public health is part of the picture too. Exchange purposes that include public health create a path for reporting and case investigation that depends on accurate clinical documentation, much of which comes from nurses.
In EHR Implementation (Go-Live Perspective)
During an Epic implementation, cross-organization exchange is configured as part of interoperability build: which networks the organization connects to, how outside records are displayed, and how incoming documents are reconciled. These connections are often validated in the weeks after Go-Live, once core workflows are stable.
End-user support analysts see the results in questions such as why outside records are missing for a particular patient or why a document did not arrive. Many of those issues trace back to patient matching or demographics entered at registration, which makes accurate front-end data a quiet contributor to nationwide interoperability.
🎓 CAHIMS / CPHIMS & HIMSS Perspective
CAHIMS Exam Domain Mapping
TEFCA is a high-yield interoperability policy topic on the CAHIMS exam:
| CAHIMS Domain | How TEFCA Appears |
|---|---|
| Healthcare & Technology Environments | 21st Century Cures Act; ONC and the RCE; QHINs and the Common Agreement; information blocking context |
| Clinical Informatics | Use of outside records in clinical workflow; transitions of care; public health reporting |
| Healthcare Information & Systems Management | Network connectivity; patient matching; document and FHIR-based exchange; privacy and security requirements |
| Management & Leadership | Interoperability strategy; participation decisions; governance of data sharing agreements |
Key Terms to Know Alongside TEFCA
- QHIN (Qualified Health Information Network) — a network designated under TEFCA to exchange data with other QHINs
- Common Agreement — the binding legal agreement that sets the terms for TEFCA participation
- Recognized Coordinating Entity (RCE) — the organization that administers TEFCA under contract with ONC
- Exchange Purposes — the defined reasons for which data may be requested and shared under TEFCA
- Health Information Exchange (HIE) — the electronic sharing of health information between organizations
- 21st Century Cures Act — the 2016 law that called for TEFCA and prohibited information blocking
HIMSS Organizational Position
HIMSS treats nationwide interoperability as a core policy priority and engages with federal agencies on TEFCA, information blocking, and related rules through its public policy work. Members can find interoperability guidance and research through the HIMSS Resource Center.
🔗 Explore Further: External References
- ONC — Trusted Exchange Framework and Common Agreement (TEFCA) https://healthit.gov/policy/tefca/
- The Sequoia Project — TEFCA Recognized Coordinating Entity https://rce.sequoiaproject.org/
- ONC — Cures Act Final Rule https://healthit.gov/regulations/cures-act-final-rule/
- ONC — Interoperability https://healthit.gov/interoperability/
- ONC — What Is HIE? https://healthit.gov/health-it-basics/hie/
- HIMSS — Public Policy and Advocacy https://www.himss.org/public-policy-advocacy-overview
Term source: HIMSS Dictionary of Health Information and Technology Terms, Acronyms, and Organizations, 6th Edition (2025). All definitions in this series are paraphrased for editorial purposes. Readers are encouraged to consult the primary source for exact language.
Eric Andrew Kristof, RN, CAHIMS is a Healthcare IT professional and HIMSS Arkansas Chapter member based in Hot Springs Village, AR, with hands-on Epic Go-Live experience and a diverse healthcare and IT background. He writes at kristof.org at the intersection of clinical care and healthcare technology.
Leave a Reply