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The Information Exchange: The TEFCA Report Card

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The Information Exchange: The TEFCA Report Card

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We are back, but we’re trying something a bit different this time. Given a little Memorial Day lead-up lull afflicting the industry, we decided to give a primer and run-down on the successes and failures of America’s only statutorily blessed nationwide health data exchange: TEFCA two years in, with what's actually working, what isn't, and what the rails really do at this point. Lot of fun this not-a-pod:* The first iteration of our new “Pryce Transparency” segment* Brad as a Trusted Exchange Guinea Pig* Five generations of patient access policy and technology in five minutes* Where Epic stands alone on a FHIR flow that's now an exhibit in active antitrust litigation.* The authentication vs. authorization debate that's becoming the most consequential architectural question in patient access.* Diagnostic imaging’s role in all this (and interop broadly)And of course, what we’re putting on our Memorial Day burgers. Hiring NoticeHTD is hiring! We are looking to bring on Associates to our Interoperability Practice.If you have experience with EHRs, interoperability, and/or consulting and want to:* Work on the deepest, darkest arts of integration and health information exchange* Help the full range from startups to the largest tech companies in the country understand and play in the interoperability landscape* Help EHRs become their better selves (both via collaboration and pressure)* Learn and use regulation deeply as a strategic lever to enable the businesses we work with* Collaborate with a scaled development team across multiple geographies (US, Poland, Argentina)Then respond to this email with your resume and the one big interoperability problem in America you’d solve if you were a policy maker.Relevant Articles* HTI-5: When the Scorpion Learns to Swim: We briefly discuss how HTI-5 is proposing to remove the main “incentive” to join TEFCA, the TEFCA Manner Exception.* Individual Access Services Open Forum: An oldie but goodie primer on how Individual Access Services works and the history behind it.* The Rise of Consumer Health On-Ramps: Detail about the “Big 4” consumer health and patient access on-ramps* Epic’s IAS Implementation: A rant from a year ago about frustrations with Epic’s Individual Access Services implementation* JG Wentworth: Pryce’s mention was like a sleeper activation codeword for me. Real nostalgia rush.* Authorization Tradeoffs: A chart I made when discussing the tradeoffs of different authorization architectures* SMART Imaging Access: Josh Mandel’s reference implementation for patient access to diagnostic images that we talk about* Much Ado about Diagnostic Images: Discussion of the ONC’s RFI on Diagnostic Imaging and a detailed overview of the space* AADJ v. Epic: The Motion to Dismiss: The antitrust case against Epic related to TEFCA IASChapters* Intro and HTD Hiring PSA (0:00 – 0:44): Brendan, Pryce, and Brad pitch HTD’s interoperability associate roles across EHR integration, HIE, payers, clearinghouses, and information blocking strategy.* Pryce Transparency (0:44 – 3:19): A foundational walkthrough of the Trusted Exchange Framework, QHINs as the Verizon and AT&T of federated clinical data, and the difference between treatment queries and Individual Access Services.* Measuring TEFCA Against Itself (3:19 – 8:06): Adoption looks lukewarm next to Carequality on document volume, but two years ago IAS was zero. Pryce’s broken query to his Athena PCP illustrates the fingerprinting problem when something fails and no one can tell whose fault it is.* Five Generations of Patient Access (8:06 – 15:35): From HIPAA right of access through View Download Transmit, scrapers, Cures Act G10 APIs, and now IAS. Each generation solved the prior bottleneck and surfaced the next. Portalitis, Kristen Valdez’s term, and why IAS still falls back to G10 like Apple Pay falls back to cash.* Diagnostic Imaging and the Limits of TEFCA (15:35 – 21:31): Brad’s CD-to-NYU story opens the question of whether new data types ride TEFCA or get their own networks. PACS unregulated, files enormous, 30 competing standards, proprietary vendor incentives. The Dutch precedent with XDS-I and TWIIN shows it can be done, and there are real reasons clinicians want pixels not just reports.* Authentication vs. Authorization (21:31 – 27:39): Pryce walks through how IAS jams identity proofing and data-release consent on rails not designed for the distinction. Epic alone runs the FHIR redirect flow, every other QHIN hands back the treatment CDA with an IAS header, and the antitrust litigation against Epic now treats that architectural choice as an exhibit.* The HIPAA Liability Math (27:39 – 30:37): Why Cleveland Clinic’s general counsel sees only downside without OIG safe harbor. The CMS Health Tech Ecosystem is pushing authentication out anyway, leaving authorization as the more interesting question, including what hospital-side authorization could have unlocked for proxy and ...

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