Health Information Exchange

How does Health Information Exchange affect your practice?

Over the past decade, hospitals and physician offices have made tremendous gains in shifting their medical record-keeping from paper to computerized systems. This shift to electronic health information and interoperability of this information, such as through the use of electronic health records (EHRs), has the potential to make care safer and more efficient and improve the patient care experience by providing timely access to health information and seamlessly coordinated care.

In an ideal state, patients’ information should automatically follow them to all of their healthcare providers, so that everyone on their care teams stays informed and provides the best treatment. Facilitating electronic exchange of this health information is critical to easing burden by ensuring that clinicians have the best information possible when making decisions about patient care.

Appropriate and timely sharing of patient information also allows clinicians to ensure patients receive timely care in the most appropriate setting by:

• Reducing duplicate testing
• Avoiding medication errors
• Avoiding readmissions
• Improving decision making
• Enhancing care coordination

What is being done to improve health information exchange and advance interoperability?

The transition to EHRs has caused frustration among clinicians who expected the electronic capture of information to make their care more efficient. Instead, many clinicians have faced increased workload and patients' and other clinicians' access to the data is not seamless. To address these challenges and improve health information exchange — most notably, in relation to nationwide interoperability and information blocking — Congress passed the 21st Century Cures Act of 2016 (known as “the Cures Act”) with bipartisan support.

Specifically, the Cures Act identified the following main priorities for improved interoperability:

• Improve data sharing across disparate networks
• Reduce information blocking
• Advance a trusted exchange framework and a common agreement for exchange between health information networks nationally
• Promote the use of APIs to support patients' ability to have greater access to their health information through, for example, smartphones

The provisions of the Cures Act aim to reduce clinicians' regulatory and administrative burden and, in the words of National Coordinator for Health IT Donald Rucker, MD, create “a health system where information flows appropriately and securely to patients and their clinicians [that] will help coordinate care and reduce costs by making care faster and less duplicative.”

What is the Trusted Exchange Framework and Common Agreement (TEFCA)?

The Trusted Exchange Framework and Common Agreement^SM (TEFCA^SM) is a framework and agreement to simplify clinical data exchange, or the way people exchange electronic health information.

The 21st Century Cures Act, which passed with strong bipartisan support, called for the development of this framework and agreement. In response, ONC published TEFCA on January 19, 2022. ONC collaborated with an industry-based nonprofit group — the Recognized Coordinating Entity^® (RCE^TM) — to create the agreement.

The two major components of TEFCA are:

• The Trusted Exchange Framework (TEF) [PDF – 299 KB]: a set of foundational principles to facilitate clinical data exchange among health information networks (HINs) and other entities
• The Common Agreement (CA) [PDF – 864 KB]: the legal contract that establishes a model with governing principles for users to follow when they share health information

The goal of TEFCA is to establish a way for people to share electronic health information securely without having to make a special effort. In health care, this is known as interoperability, and it allows for complete access, exchange, and use of all electronically accessible health information for authorized use under applicable State or Federal law.

Using the framework and common agreement, many different entities will be able to send, receive, and query for standardized electronic health information locally and nationally. TEFCA will make it easier for providers, payers, and consumers to access health information, supporting better clinical decision-making, improved outcomes, and lower costs. Specifically, TEFCA will improve patient care and help health care providers:

• Coordinate with other providers
• Give patients access to their health information
• Access information needed to support value-based care, care management, and population health
• Ease the burden of public health reporting
• Prepare for and respond to emergencies
• Increase confidence in data received from others

To learn about TEFCA, health care providers are encouraged to:

• Review the Trusted Exchange Framework, Common Agreement, QHIN^TM Technical Framework, and the educational materials on the RCE's website
• Consider scenarios within their everyday practice that could be supported through TEFCA
• Evaluate their existing health information network partnerships and ask whether partners are planning to participate in TEFCA
• Evaluate how their existing electronic health record supports information exchange
• Ask how their vendors are preparing for TEFCA

How do Application Programming Interfaces (APIs) support health information exchange and interoperability?

APIs are technology that allow one software program to access the services provided by another software program. APIs hold the ability to revolutionize healthcare data sharing, as it has already revolutionized data sharing in other sectors such as the financial and airline industries. Online and smart phone banking are enabled by APIs. APIs can also help healthcare professionals improve and simplify care delivery in a number of ways.

• Using APIs as part of EHRs can make it easier for patients to get and share important health information.
• APIs can also help healthcare providers share patient information with other providers securely and efficiently.
• They may also enable clinicians to more easily exchange information for other purposes. For instance, clinicians may use a smartphone app to submit data to a registry in support of public health or quality reporting.

Explore these resources to learn more about APIs:

• API Learning Module: Interactive
• API Learning Module: Video
• Key Privacy and Security Considerations for Healthcare Application Programming Interfaces (APIs) [PDF – 522 KB]

Clinicians use Directed Exchange to easily and securely send patient information — such as laboratory orders and results, patient referrals, or discharge summaries — directly to another healthcare professional.

Healthcare professionals, who already know and trust each other, send this information over the internet in an encrypted, secure, and reliable way; it’s commonly compared to sending a secured email. This form of information exchange enables coordinated care that benefits both clinicians and patients.

A primary care clinician can, for example, directly send electronic care summaries that include medications, problems, and lab results to a specialist when referring their patients. This information helps to inform the visit and prevents:

• Duplication of tests
• Redundant collection of patient information
• Wasted visits
• Medication errors

If a clinician receives laboratory results electronically and incorporates them into an electronic health record (EHR) they can, for example, generate a list of patients with diabetes. The clinician can then determine which of these patients have uncontrolled blood sugar and schedule necessary follow-up appointments.

Clinicians also use Directed Exchange to send immunization data to public health organizations, or to report quality measures to The Centers for Medicare & Medicaid Services (CMS).

Admission, discharge, or transfer (ADT) messages are the vehicle for communicating updates about a patient’s care transitions. The messages provide each patient’s personal or demographic information (such as name, insurance, next of kin, and attending physician) and notes when that information has been updated. They also indicate when an ADT status has changed — an admission or discharge, for example. Here’s how ADT alerts work:

• The alerts are triggered by an admission, discharge, or transfer (ADT) event in a hospital information system that sends a message to the health information exchange system
• The health information exchange system processes the message and transforms it into an alert sent to the primary care practice or community-based care manager
• This communication notifies the physician, care manager, or care management team to initiate an intervention, thus improving the post-discharge transition and supporting management of patients with chronic conditions

A transition of care is the movement of a patient from one clinician or clinical setting of care to another clinician or setting of care. For example, a transition of care occurs when a primary care clinician (PCP) refers a patient to a specialist, or when a hospital discharges a patient to another care setting.

In many cases, but not all, a transition of care is permanent. For example, when a clinician discharges a patient from an inpatient setting, the discharging clinician expects that the patient will not return. When a PCP refers a patient to a specialist, such a referral is a transition of care; however, the PCP typically expects the patient to return for subsequent follow-up care.

A patient’s transition in care gives both the sending and receiving clinicians an important opportunity to exchange patient information and reduce gaps in care. Having relevant patient information available when a patient transitions lets clinicians reconcile medications and other clinical information when patients transfer to their new setting.

Standards, in the context of health IT, refer to agreed-on file formats for electronic documents, messages, and other healthcare related data elements. These standard formats allow for the creation of electronic messages that are exchanged between different health IT systems, which make interoperability and health information exchange possible.

There are many types of health standards and they are often used in varying levels within health IT systems. Here are a few common types of standards: The standards and associated implementation specifications for clinical health information are grouped into 4 categories:

Terminology standards: Terminology standards specify which terms are to be used in a particular clinical domain and how each term in the system is defined (e.g., “weight” versus “birth weight” versus “dosing weight”). Terminology standards also define the vocabulary or code sets that pertain to a particular clinical domain or data type.

Content standards: Content standards define the structure (syntax) for information that may be packaged for exchange. Content standards may define the data to be included, define the document structure, or include metadata about the information to be exchanged.

Transport standards: Transport standards specify how data are to be packaged and transported between systems. Successful transport between systems leads to the ability of disparate systems to work together (interoperability). Transport standards often define “how” information is exchanged (the method by which information moves from point A to point B).

Services standards: Services standards specify the infrastructure components deployed and used to accomplish specific information exchange objectives (for example, standards and specifications for how information may be “pushed” to a known destination or specifications for how to query for a document)

Other standards include security standards and process standards that are not unique to healthcare — such as security standards for accessing the internet or process, or quality standards for ensuring products or services consistently meet customer requirements.

Successful exchange of electronic messages — using standards listed above — between systems leads to the ability of disparate systems to work together (interoperability).