If you run a small practice, here is the honest summary of TEFCA: you do not join TEFCA directly, and you certainly do not become a QHIN. You connect through somebody — your EHR vendor, a regional health information exchange, a health system you are affiliated with — and in TEFCA's vocabulary you become a Participant or a Subparticipant under a Qualified Health Information Network. For most practices the entire decision reduces to one question asked of one vendor. The rest of this article is the context that makes that question answerable, and the answers you should accept.
The short answer for a small practice
- TEFCA is a nationwide framework for sharing health records — ONC describes it as a "network-of-networks" that creates a universal floor for interoperability so data can move beyond proprietary boundaries.
- QHINs are the large networks at the center of it. They are the connection points that exchange with each other.
- You are a Participant or Subparticipant. You reach TEFCA by connecting to an organization that has already done the hard part.
- Your action item is a question to your EHR vendor, not a procurement project.
What TEFCA is
The Trusted Exchange Framework and Common Agreement was created by ONC to remove barriers to sharing health records electronically among providers, patients, public health agencies, and payers. It was formally announced in 2022, and it crossed its most important milestone in December 2023, when the first Qualified Health Information Networks were designated and data began flowing between them within days.
Structurally it rests on three documents, all published by ONC:
| Document | What it does |
|---|---|
| Trusted Exchange Framework (TEF) | The principles — standardization, openness and transparency, cooperation and non-discrimination, privacy, security and safety, access, equity, and public health |
| Common Agreement | The legal contract every QHIN signs. Sets the baseline legal and technical requirements, the infrastructure model, and the governing approach |
| QHIN Technical Framework (QTF) | The technical requirements for exchange between QHINs — patient identity resolution, authentication, performance — with requirements that flow down to Participants and Subparticipants |
The Common Agreement and the QTF are versioned and updated over time, and the QTF is incorporated by reference into the Common Agreement. That matters more than it sounds: the technical obligations that eventually reach your practice arrive by flow-down from a contract you never personally signed.
Who does what: ONC, the RCE, QHINs, Participants
| Role | Who | What they do |
|---|---|---|
| Policy lead | ONC | Sets TEFCA policy, guides network governance, coordinates with federal partners |
| Recognized Coordinating Entity (RCE) | The Sequoia Project, under a five-year contract with ONC awarded in August 2023 | Develops and maintains the Common Agreement, runs the QHIN application and designation process, monitors designated QHINs, updates the QTF |
| QHIN | Large health information networks that applied and were designated | The backbone. QHINs exchange with each other using TEFCA's technical standards |
| Participant | Hospitals, health systems, public health agencies, regional HIEs, and other organizations | Connect to a QHIN and exchange data through it |
| Subparticipant | Most small practices land here | Connect under a Participant — often a regional HIE or an EHR vendor acting as a Participant |
Becoming a QHIN is not a light lift: per ONC, a network must be a U.S. entity, complete the application, onboarding and designation process, and sign the Common Agreement — a rigorous process that typically takes about twelve months. This is precisely why the small-practice path runs through someone else.
What you can exchange data for
TEFCA is designed to support exchange for any purpose, but the purpose must be stated in each request. The initial Exchange Purposes are:
- Treatment
- Payment
- Health care operations
- Public Health
- Government benefits determination
- Individual access services
ONC and the RCE expand these over time as the QHIN Governing Council raises market needs, so the list is a floor rather than a ceiling. For a typical outpatient practice, Treatment is the one that changes daily life: a new patient walks in, and their records from a hospital or specialist elsewhere in the country can be requested through the network rather than chased by fax.
How a practice actually connects
- Ask your EHR vendor first. Many vendors are QHINs, are Participants under a QHIN, or have partnered with one. If yours has, connecting may be a configuration and contracting exercise rather than a new integration.
- Check your regional or state HIE. If you already exchange through an HIE, ask whether it is a QHIN or a Participant under one. If it is, your existing connection may be your on-ramp.
- Check your affiliations. Practices affiliated with a health system, IPA or ACO may reach TEFCA through that relationship.
- Read the flow-down terms before signing. Whoever you connect through will pass along obligations from the Common Agreement's Participant and Subparticipant terms. These are real contractual commitments about how you request and respond to data. Have someone read them.
- Do not treat this as urgent procurement. There is no penalty for not being in TEFCA. It is an opportunity to reduce record-chasing, not a compliance deadline.
What to ask your EHR vendor
- Are you a designated QHIN, a Participant under a QHIN, or neither? If a Participant, under which QHIN?
- If we connect through you, are we a Participant or a Subparticipant, and what terms flow down to us?
- What does TEFCA connectivity cost — one-time, recurring, and per-transaction?
- Which Exchange Purposes are supported today in our configuration? Treatment only, or more?
- How does a TEFCA query appear in the clinical workflow? Is it a button in the chart, or a separate portal someone has to remember to check? This determines whether it gets used.
- How does TEFCA exchange interact with the networks we already use, and are we going to be paying twice for the same records?
What TEFCA is not
- Not a mandate. No regulation requires a practice to join TEFCA. It is voluntary participation in a framework.
- Not a replacement for HIPAA. Your Privacy and Security Rule obligations are unchanged. TEFCA adds contractual requirements on top; it subtracts nothing.
- Not the same thing as the information blocking rule. Information blocking obligations apply to you whether or not you ever touch TEFCA. Do not let a vendor bundle the two.
- Not automatic. Being on an EHR whose vendor is a QHIN does not mean your practice is exchanging through TEFCA. Someone has to turn it on and sign something.
Common questions
Does my small practice need to join TEFCA?
No. TEFCA participation is voluntary, and no rule requires a practice to join. The practical question is whether connecting — usually through your EHR vendor or a regional HIE — would save you enough record-chasing to be worth the cost and the contract terms.
Can a small practice become a QHIN?
Realistically, no. A QHIN must be a U.S. entity that completes ONC and RCE's application, onboarding and designation process and signs the Common Agreement — a rigorous process that ONC says typically takes about twelve months. QHINs are networks, not practices. You participate through one.
What is the difference between a Participant and a Subparticipant?
Participants connect directly to a QHIN — typically hospitals, health systems, public health agencies, and regional HIEs. Subparticipants connect under a Participant. Most small practices end up as Subparticipants, reaching the network through their EHR vendor or their regional HIE.
Who runs TEFCA day to day?
ONC owns the policy. The Recognized Coordinating Entity — The Sequoia Project, under a five-year contract with ONC awarded in August 2023 — develops and maintains the Common Agreement, runs the QHIN application and designation process, monitors designated QHINs, and updates the QHIN Technical Framework.
Common questions
Does my small practice need to join TEFCA?
No. TEFCA participation is voluntary and no regulation requires a practice to join. The practical question is whether connecting — normally through your EHR vendor or a regional HIE — saves enough record-chasing to justify the cost and the contractual terms that flow down to you.
Can a small practice become a QHIN?
Realistically no. A QHIN must be a U.S. entity that completes the application, onboarding and designation process run by ONC's Recognized Coordinating Entity and signs the Common Agreement — a rigorous process ONC says typically takes about twelve months. QHINs are networks, not practices.
What is the difference between a Participant and a Subparticipant?
Participants connect directly to a QHIN and are typically hospitals, health systems, public health agencies and regional HIEs. Subparticipants connect under a Participant. Most small practices are Subparticipants, reaching TEFCA through their EHR vendor or regional HIE.
What can data be exchanged for under TEFCA?
Each request must state its purpose. The initial Exchange Purposes are Treatment, Payment, Health care operations, Public Health, Government benefits determination, and Individual access services. ONC and the Recognized Coordinating Entity expand the list over time.