The N.C. Health Information Exchange Authority is providing information about the Trusted Exchange Framework and Common Agreement, known as TEFCA. This framework and agreement was drafted by The Sequoia Project, the Recognized Coordinating Entity of the U.S. Department of Health and Human Services.

Last updated Jan. 3, 2024

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TEFCA is a governance agreement that supports the bi-directional exchange of health records on a national scale. It both defines the legal and technical requirements for secure information exchange and outlines a set of principles to facilitate trust between networks. These principles include standardization, openness, security, privacy and cooperation.

The development of TEFCA was first mandated in 2016 under the 21st Century Cures Act. The Sequoia Project, the Recognized Coordinating Entity of the Office of the National Coordinator, developed TEFCA and supports its implementation. The publication of TEFCA was finalized in 2022.

Participation in the TEFCA Exchange Framework is currently voluntary.

The pillars of TEFCA are the Qualified Health Information Networks, or QHINs. QHINs are responsible for routing queries, responses and messages between members (subparticipants) of participating HIEs. These subparticipants would be entities such as health systems and health care providers.

Several health information networks were approved as applicants for QHIN status in early 2023. Five of these networks, eHealth Exchange, Epic Nexus, Health Gorilla, KONZA National Network and MedAllies, have now completed their implementations and are officially designated as the country’s first QHINs. The remaining applicants continue to work to complete their implementations.

Infographic explaining structure of TEFCA as described in the article.


Participation in TEFCA is optional, but participants can only be a part of one QHIN at any time. For example, a health care system that uses Epic may choose to be a part of the Epic QHIN, but they cannot then be part of the eHealth Exchange QHIN or be a subparticipant of another TEFCA member.

All HIEs face a pivotal decision at this time to become a QHIN or to connect to a QHIN as a participant. Organizations can opt in or out at any time.

An individual provider would not be a direct participant in TEFCA. They could potentially be connected by being a subparticipant of an existing TEFCA participant (such as a health system or health information exchange connected to a QHIN) or by connecting directly to a QHIN.

Participation in TEFCA does not prevent an organization from also connecting to their local HIE, such as NC HealthConnex, the state-designated health information exchange for North Carolina, and benefitting from query-based exchange and other services such as ADT alerts and population health tools. TEFCA is intended to complement existing exchanges.

At this time, we have chosen to opt out of participation in TEFCA for year one. Note that this does not change our current data connections with eHealth Exchange that enable exchange with neighboring states’ HIEs and health care providers. NC HealthConnex is currently serving the needs of North Carolina health care providers with regional health information exchange services. We already have a considerable amount of CCD exchange currently happening over eHealth Exchange.

The NC HIEA is continuing to follow TEFCA as it matures and becomes a more fully realized and robust network. Organizations have the right to opt in or out to TEFCA at any time. We plan to reevaluate our participation in TEFCA once it is FHIR enabled. This development is planned for year two.

We also welcome feedback and questions from our participants to determine if there is a large demand for TEFCA involvement from North Carolina providers. Please reach out to us at hiea@nc.gov with your thoughts and questions.

It depends. Not every eHealth Exchange participant is also a participant in TEFCA as this is a voluntary network and has only recently gone live. We expect more organizations to sign on to TEFCA once it is FHIR enabled. With a full participation agreement, your practice will have access to the data within eHealth Exchange that comes from other eHealth Exchange participants.

Once NC HealthConnex opts in to participate in TEFCA through the eHealth Exchange QHIN, then we would have access to data sharing via the other TEFCA QHINs. Note: NC HealthConnex already exchanges data across state lines with HIEs in 25 other states through our participation in eHealth Exchange and the Patient Centered Data Home (PCDH).

You will be receiving a significant amount of data from CCDs and ADTs from our North Carolina participants already connected to the state-designated health information exchange, NC HealthConnex. You can view a list or a map of who is connected on our website. You will also receive CCDs from those connected to the eHealth Exchange and ADT alerts across state lines through the Patient Centered Data Home (PCDH).


Information on TEFCA can be found on the website for The Sequoia Project.

Information related to eHealth Exchange and TEFCA can be found on that organization's FAQ page.