What is TEFCA? The Common Agreement, QHINs and exchange purposes, explained

The short answer

TEFCA, the Trusted Exchange Framework and Common Agreement, is a nationwide US framework for sharing health information across networks.¹ Networks that complete an application and onboarding process and sign the Common Agreement become Qualified Health Information Networks (QHINs), the backbone that connects everyone else. The Sequoia Project serves as the Recognized Coordinating Entity (RCE) under a five-year ONC contract awarded in August 2023.¹ The first QHINs were designated in December 2023, and data started flowing within days.¹ Exchange is tied to specific purposes: treatment, payment, health care operations, public health, government benefits determination and individual access services.¹

Why TEFCA exists

Before TEFCA, an organisation that wanted to exchange records widely had to join several networks, sign several legal agreements, or build one-off interfaces. TEFCA’s aim is a single set of principles, terms and conditions, so that joining once connects you broadly. The RCE describes the goals as making a core set of data available across connected networks, reducing the need for multiple network memberships and point-to-point interfaces, and giving networks common privacy and security requirements.²

Exchange in the US still runs heavily on older standards. In a 2023 survey, 96% of health information exchanges reported receiving HL7 v2 ADT messages.⁴ TEFCA sits above the message formats: it’s mainly about who may exchange with whom, for what, under which rules.

The structure

Code What the screen or file shows, copied as is.

               ASTP/ONC
                  │  oversees
          RCE (The Sequoia Project)
                  │  coordinates, runs designation
   ┌──────────────┼──────────────┐
  QHIN A        QHIN B        QHIN C      ← connected to each other
   │              │              │
 Participants  Participants  Participants   (providers, plans, HIEs, vendors)
   │
 Subparticipants

Participants and subparticipants are how most hospitals, clinics, plans and vendors connect: through a QHIN, not directly to every other organisation.

The exchange purposes

Every TEFCA exchange must be for a recognised purpose. ASTP/ONC lists six initial ones:¹

Purposes do real work. A request has to state one, and the responder relies on it. An organisation can’t use a treatment query to collect data for analytics.

That makes the purpose field one of the most consequential values any system sets. When a person makes the request, their role and the context usually make the purpose obvious. When software makes it on someone’s behalf, the purpose has to be set deliberately in configuration, tied to the workflow that triggered it, and recorded with the query. A default value copied from a template is how purpose drift starts.

TEFCA and information blocking

TEFCA connects to the information blocking rule in a specific way. That rule bars actors (providers, certain health IT developers, networks and exchanges) from practices likely to interfere with access, exchange or use of electronic health information, unless an exception applies.³ One exception, the TEFCA manner exception in 45 CFR 171.403, covers fulfilling a request through TEFCA under its conditions.³ Our information blocking post covers all ten exceptions.

What TEFCA means for AI tools

TEFCA doesn’t mention AI. But AI tools increasingly sit behind the requests, and the framework’s design has consequences:

• The purpose belongs to the request, not the tool. An AI tool that pulls records via a participant’s TEFCA connection is making a request for a stated purpose. If the clinician asked it to prepare for a visit, that’s treatment. If it’s building a training set, that’s a different purpose, and probably not one TEFCA covers.
• Broad reach, broad exposure. TEFCA’s point is that one connection reaches many networks.² An AI agent with access to that connection can retrieve a lot quickly. Scope what it can query, log every query with its purpose, and review volume.
• Individual access is a real channel. Patients using apps to retrieve their records through individual access services may feed those records to AI assistants. That’s the patient’s choice; the app still carries privacy responsibilities.
• Records of what was asked, by whom, and why. If a query’s purpose is ever questioned, the requester needs to show who asked the AI tool to make it and on what basis. Logs that only show “the integration account” won’t do.

A checklist for organisations connecting AI tools to TEFCA-connected systems:

1. Map each AI use to one exchange purpose, and refuse uses that don’t fit.¹
2. Give each tool its own identity in the participant’s systems.
3. Log each query with the purpose, the requesting person or workflow, and the records returned.
4. Apply minimum-necessary limits where HIPAA requires them; our minimum necessary post shows how.
5. Review query volumes per tool monthly.

Questions people ask

What is a QHIN?

A Qualified Health Information Network: a network that completed TEFCA’s application and onboarding, signed the Common Agreement, and is designated as part of the backbone.¹

Who runs TEFCA?

ASTP/ONC oversees it; The Sequoia Project is the Recognized Coordinating Entity under a contract awarded in August 2023.¹

When did TEFCA exchange start?

The first QHINs were designated in December 2023, with data flowing within days.¹

For how agent queries and writes can be scoped and recorded, see our healthcare page and the provenance spec. To try approvals and read-backs on a real database in your browser, open the playground; to grade what an agent can reach on your own machine, run npx deedglass scan (the grade, explained).

Written with AI assistance and checked against our claims register.