The Promise and Potential of Clinical Data Exchange

Healthcare leaders are under increased pressure to exchange electronic clinical information to reduce cost, improve patient outcomes, and comply with regulatory reporting standards. As many payers struggle with finding the right data partners, providers are missing information needed to manage outcomes and close gaps in care. The industry-wide standardization of interoperability protocols supports nationwide interoperability and presents the opportunity to improve clinical quality outcomes while reducing payer and health system costs.

Previously, there was little clarity regarding the permitted exchange purposes for electronic health data. Many organizations and national networks, such as eHealth Exchange, have long supported interoperability for treatment, payment, and healthcare operations (TPO). However, health systems and health information exchanges (HIEs) were only required to respond to queries for treatment and, more recently, individual access.

This, combined with a lack of technical standards, created data silos and duplicative workflows, resulting in high costs for payers, health systems, and their business associates. The 21^st Century Cures Act (Cures Act) acknowledged these challenges and, through the Trusted Exchange Framework and Common Agreement (TEFCA), created an industry-wide framework of standardized  protocols and exchange purposes to support interoperability at scale.

TEFCA’s Influence on the Healthcare Industry

TEFCA is intended to serve as a single “on-ramp” for stakeholders to participate in nationwide data exchange for a variety of purposes such as TPO, public health, individual access, and government benefits determination. As payers often require supplemental clinical information from the patient encounter (in addition to a coded claim), the Cures Act brings an increased focus on improving data to support use cases such as risk adjustment, payment integrity, and Healthcare Effectiveness Data and Information Set (HEDIS®) reporting. This is especially relevant in value-based care arrangements to determine the appropriateness of the treatment and medical necessity. Additionally, the data exchanged between payers and providers can also be used to improve outcomes by closing care gaps or preventing admissions.

Notably, TEFCA is not a network or HIE. Rather, it is a federally endorsed framework providing the technical and policy guardrails to enable cross-network data exchange through Qualified Health Information Networks (QHINs). While the Office of the National Coordinator for Health Information Technology (ONC) defines the overarching policy and governance requirements, it is the recognized coordinating entity (RCE), The Sequoia Project, that provides oversight. The role of the QHINs is to connect directly to each other to facilitate national data exchange for the outlined exchange purposes. Given the complexity and volume of queries, organizations that want to become a designated QHIN under TEFCA must participate in a rigorous application and onboarding process.

QHIN Data Exchange for Payers and Delegates

In December 2023, five organizations achieved the QHIN designation: Epic Nexus, eHealth Exchange, KONZA, MedAllies, and Health Gorilla. An additional two QHINs, CommonWell Health Alliance and Kno2, were announced as approved in early 2024. These QHINs are currently working to configure their production systems for connectivity and onboarding their participants. Once this is completed, any TEFCA participant regardless of QHIN can query other participant organizations seamlessly.

Historically, payers have acquired clinical data from providers using various retrieval methods that required health information management (HIM) resources including onsite retrieval agents, fax, or web portals. Aside from being expensive and time-consuming, these approaches fail to provide health plans with the structured data needed to drive insights. Now, payers and their business associates can leverage TEFCA’s “network of networks” approach to exchange data as a QHIN participant or sub-participant, reducing the need for HI staff to manually release these records. While interoperability at scale is possible under TEFCA, data availability will remain fragmented until the majority of payers join a QHIN.

In January, the latest draft version of the Common Agreement (v2) and Standard Operating Procedures (SOPs) were released for public comment. The draft Common Agreement v2 provides support for Fast Healthcare Interoperability Resources (FHIR)-based transactions and is on track to be adopted by the QHINs in the first quarter of the year.

Both the Common Agreement and SOPs are important for payers and, by extension, HIM professionals, as they include a carve-out for delegation of authority and support healthcare operations exchange purposes. For payers, a delegate under TEFCA may include a business associate that performs medical record retrieval on their behalf. Health plans wishing to obtain data from a QHIN will need to ensure they are listed as a principal in the RCE directory.

In addition, payers must be prepared to share adjudicated claims data back to the requestor in the FHIR format if the request was sent through the TEFCA—as opposed to faxing this information back to HIM departments, which can jeopardize patient privacy. Health plans can now accomplish this task independently by leveraging protocols such as the CARIN Common Payer Consumer Data Set or the DaVinci Payer Data Exchange (PDex) implementation guide.

Recommendations for Improving Interoperability

As the industry continues to advance in areas such as digital quality measures and electronic prior authorization, a streamlined approach to clinical data sharing is necessary to mitigate technical debt, reduce provider abrasion, and improve efficiencies across the care continuum. To this end, it will become critical for payers to participate in TEFCA exchange directly or through a delegate.

Joining a QHIN reduces the need for payers to create one-off integrations for clinical data sharing, eliminating the need for intricate service agreements, complex integrations, and HIM involvement. Frequently, vendors struggle with inadequate patient matching logic or low provider response, which has a negative impact on workflow. Having a single connection to a QHIN, either directly or through a delegate, allows payers to obtain high-quality clinical information in a timely manner.

Furthermore, participation will limit payer and HIM interaction with copy service vendors and reduce dependencies on expensive retrieval partners. To optimize the amount of information returned, health plans can work with in-network providers to respond to all TEFCA exchange purposes. Participants and sub-participants have the ability to choose which QHIN to join. Organizations should consider the support structure, business models, and strategic priorities of each QHIN when choosing their partner.

While participation in TEFCA is not mandatory, it is expected to yield consistent results, improved match rates, and use high-quality data while alleviating the administrative burden on HIM professionals.  The need for copy service partners and faxing will not completely vanish as these changes come to fruition. However, as QHIN participation grows, HIM leaders should prepare to see a reduction in medical record requests that need manual intervention.

Katie Devlin, DHSc, MS, CPHIMS, is vice president of interoperability at Cotiviti, a provider of data-driven healthcare solutions. Devlin is responsible for creating an enterprise-wide health data exchange strategy. She oversees all initiatives related to digital health data acquisition, ingestion, storage, and normalization, and is an advocate for ensuring health information is delivered in a way that enhances the member, provider, and payer experience.