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TEFCATrusted Exchange Framework and Common Agreement

In short

TEFCA is the United States' national framework for health information networks to connect with each other under common rules. Through a single agreement, an organization connected to a qualified network can exchange data with the other QHINs and their participants. Participation is voluntary and is defined by a common contract, not by a central database.

Type
Legal framework
Steward
ONC (HHS); Recognized Coordinating Entity: The Sequoia Project
Current version
Common Agreement 2.1
Jurisdiction
United States
Reviewed
October 25, 2026

Explanation

What it is

The 21st Century Cures Act, of December 2016, directed the National Coordinator for Health IT to convene public and private stakeholders to develop or support a trusted exchange framework and a common agreement for exchange between health information networks (42 U.S.C. 300jj-11). The same law states that nothing requires a network to adopt it.

Today it is run by ONC, the Office of the National Coordinator for Health IT within the Department of Health and Human Services (HHS). Until 2026 it was called ASTP/ONC: an HHS notice published on 1 April 2026 removed the ASTP role and restored the ONC name. The Sequoia Project serves as the Recognized Coordinating Entity (RCE) under a five-year contract awarded in August 2023.

How it works

ActorRole
ONC (formerly ASTP/ONC)Defines overall policy and certain governance requirements
RCEOversees QHINs and provides a governing approach
QHINs (qualified networks)Connect directly to each other
Participants and SubparticipantsConnect through a QHIN and agree to the same Terms of Participation

The Common Agreement is the contract signed by all QHINs; it sets baseline legal and technical requirements. The QHIN Technical Framework (QTF), incorporated by reference, covers patient identity resolution, authentication and performance measurement.

Every transaction must assert an exchange purpose code. The authorized purposes are treatment, payment, health care operations, public health, government benefits determination and individual access services.

Status as of October 2026

  • Common Agreement 2.1, released in November 2024 (earlier: 1.0 in January 2022, 1.1 in November 2023, 2.0 in April 2024).
  • QTF 2.1, effective 4 December 2025, which allows a query to be directed to a specific node.
  • The first QHINs were designated in December 2023; the RCE list includes 11 designated QHINs.
  • According to ASTP/ONC (February 2026), since December 2023 more than 70,000 sites participate and more than 474 million documents have been shared.
  • The December 2024 final rule (effective 15 January 2025) created 45 CFR part 172, with the requirements and processes for QHIN designation, suspension, termination and appeals.

Common misconceptions

  • Believing it is mandatory. The law defines it as voluntary.
  • Picturing a national database. TEFCA is a network of networks: QHINs connect to each other and participants exchange through them.
  • Thinking it is only for care. It includes public health, government benefits determination and patients' own access.
  • Confusing a QHIN with a participant. A hospital can connect as a participant or subparticipant; to become a QHIN an entity must be a US entity, sign the Common Agreement and complete a designation process of about 12 months.

Usage examples

  1. The Indian Health Service (IHS) was the first federal partner to sign an agreement with a QHIN, according to an ASTP/ONC presentation of February 2026.

  2. The Social Security Administration developed with ONC (then ASTP/ONC) use cases for the government benefits determination purpose, whose SOP 1.0 has been effective since 4 December 2025, and signed an agreement with a QHIN.

  3. The Consumer Product Safety Commission signed an agreement with a QHIN to exchange data under the public health purpose.

  4. Within the public health purpose, TEFCA defines its own codes for electronic case reporting and electronic lab reporting.

  5. The Facilitated FHIR Implementation SOP, version 2.0, has been effective since 8 March 2026.

  6. A physician at a participating hospital queries, for treatment, the documents of a patient previously seen in another state by a provider connected to another QHIN.

Relation to other terms

Relies on4

  • Cures ActRequired

    Section 4003 of the 21st Century Cures Act directed the convening of the trusted exchange framework and common agreement (42 U.S.C. 300jj-11).

  • HIERequired

    TEFCA is an agreement among health information networks: without them it has nothing to connect.

  • FHIRMedium

    TEFCA has a standard operating procedure for facilitated FHIR exchange, which coexists with document-based exchange.

  • MPI / EMPIMedium

    The QHIN Technical Framework covers patient identity resolution across networks.

Depend on this one1

  • Information blockingMedium

    One of the ten current exceptions, the TEFCA manner exception, depends on the parties taking part in TEFCA; the proposed HTI-5 rule would remove it.

Sources

  1. HealthIT.gov — Trusted Exchange Framework and Common Agreement (TEFCA)healthit.gov
  2. 42 U.S.C. 300jj-11 — Office of the National Coordinator (U.S. Code, govinfo)govinfo.gov
  3. The Sequoia Project (RCE) — Common Agreementrce.sequoiaproject.org
  4. The Sequoia Project (RCE) — Designated QHINsrce.sequoiaproject.org
  5. ASTP/ONC — TEFCA Update (19 February 2026)healthit.gov
  6. Federal Register — Health Data, Technology, and Interoperability: TEFCA final rule (89 FR 101772, 16 December 2024)federalregister.gov
  7. Federal Register — HHS Statement of Organization: Office of the National Coordinator for Health IT (91 FR 16204, 1 April 2026)federalregister.gov
Health interoperability glossary