TEFCA at the Crossroads: Adoption Reality, QHIN Momentum
What’s Next for Nationwide Interoperability
When you say “TEFCA” in the hallway of a health system or vendor headquarters today, you are more likely to get a thoughtful pause than a shrug. That pause matters. It signals a shift. The Trusted Exchange Framework and Common Agreement was designed to be the national on-ramp to interoperability. Instead, its early years have been marked by careful governance, deliberate infrastructure building, and uneven but real adoption.
Now, TEFCA is no longer theoretical. It is operational, contractual, and increasingly measurable. The question leaders should be asking is not whether TEFCA exists, but whether it is being used in ways that materially change care coordination, public health response, and patient access. In this post, I will walk through where TEFCA stands today, how QHINs are performing, and where adoption still needs executive-level intervention. This is not a status update. It is a progress check with opinions.
1. TEFCA Implementation: Where We Are Now
Since late 2023, TEFCA has moved decisively from policy to production.
The Sequoia Project currently serves as the Assistant Secretary for Technology Policy’s Recognized Coordinating Entity under contract with ASTP. In this role, Sequoia develops, updates, implements, and maintains the Common Agreement. It also reviews applications from Health Information Networks seeking QHIN designation, administers that designation, and monitors ongoing compliance.
As of 2025 and early 2026:
TEFCA is live and operational nationwide.
More than 9,000 organizations are connected through TEFCA-enabled networks.
Tens of millions of clinical documents have been exchanged under the framework.
This matters because TEFCA has crossed the threshold that many federal initiatives never reach. It is no longer aspirational. It is infrastructure.
That said, infrastructure alone does not guarantee transformation. Connectivity is a prerequisite, not an outcome.
2. QHIN Status: Who Is Live and Why It Matters
Qualified Health Information Networks are the backbone of TEFCA. They are responsible for federating existing networks and enabling exchange across organizational and vendor boundaries.
As of now, designated QHINs include:
CommonWell Health Alliance
eClinicalWorks
eHealth Exchange
Epic Nexus
Health Gorilla
Kno2
KONZA
MedAllies
Surescripts Health Information Network
Netsmart
This is a strong list. It represents major EHR vendors, national exchange operators, and networks with deep provider penetration.
Collectively, these QHINs support more than 40,000 clinicians, hospitals, long-term care facilities, and public health entities. From a governance standpoint, that is meaningful progress.
From an operational standpoint, QHIN designation signals that a network has met federal expectations around security, identity verification, permitted uses, and compliance monitoring. What it does not automatically guarantee is consistent daily use, seamless patient matching, or deeply integrated workflows.
Leadership takeaway: QHIN status is necessary but not sufficient.
3. Adoption Metrics That Actually Matter
Press releases tend to emphasize connection counts. Executives should be looking at usage patterns.
Here is what stands out:
Monthly document exchange volumes increased significantly through late 2024 and into 2025, indicating repeat and sustained use.
Epic Nexus brought immediate scale to TEFCA by enabling exchange across a large hospital and ambulatory footprint.
Large ambulatory platforms such as athenahealth have publicly committed to full TEFCA integration across their customer base.
This is real adoption, not checkbox compliance.
However, most current exchange activity remains document-centric and episodic. Longitudinal data access, real-time query response, and API-driven workflows are still limited in many environments.
In other words, TEFCA is being used, but not yet fully leveraged.
4. What the Sequoia Project Leadership Is Actually Saying
In a recent interview on Healthcare IT Today’s YouTube channel, Mariann Yeager, President of The Sequoia Project, offered insights that are worth more than a sound bite.
Two themes stood out.
First, the focus has shifted from designation to productivity. Yeager emphasized the role of working groups focused on compliance, privacy, and the usability of real-world data. This signals a maturation phase. The work is no longer just about onboarding. It is about improving how exchange actually functions at scale.
Second, she acknowledged ongoing challenges around stakeholder engagement, particularly among public health agencies and smaller regional networks. That candor matters. TEFCA is being governed as a living framework, not a frozen policy artifact.
Credit: Healthcare IT Today, YouTube interview with Mariann Yeager, President of The Sequoia Project.
For leaders, the message is clear. TEFCA governance is evolving in response to implementation realities. Organizations that engage early in this phase will have more influence than those that wait for perfect stability.
5. Where Adoption Still Needs Work
This is where the conversation gets uncomfortable and necessary.
FHIR and API-based exchange
TEFCA supports modern interoperability, but FHIR-based workflows are not yet the norm across QHINs. Many implementations still default to document exchange because it is familiar and easier to operationalize. That limits innovation.
Patient identity and matching
TEFCA does not eliminate the complexity of patient matching. It formalizes responsibility but does not solve the problem. Inconsistent demographic data and variable matching strategies remain a significant barrier to trust in exchanged data.
Payer participation
Provider networks are leading adoption. Payers are lagging. Until payer data flows are fully integrated into TEFCA-enabled exchange, value-based care workflows will remain fragmented.
Public health integration
Public health agencies are participating, but unevenly. Reporting and query use cases exist, but they are not yet ubiquitous or standardized across states.
These are not failures. They are the next phase of work.
6. What Healthcare IT Leaders Should Do Now
If you are a CIO, CMIO, product leader, or digital health executive, here is the practical agenda:
Treat TEFCA as a platform strategy, not a compliance project.
Invest in FHIR readiness and API governance now.
Develop a clear patient identity and consent strategy aligned with TEFCA workflows.
Push vendor partners on how TEFCA data can support analytics, quality, and care coordination, not just exchange.
Engage public health partners proactively instead of reactively.
TEFCA will not create value on its own. Leadership decisions will.
TEFCA has reached an inflection point. It is live, governed, and increasingly used. QHINs are operational. Exchange volumes are growing. The foundation is in place.
What comes next depends on how aggressively the industry moves beyond connection toward usability, automation, and trust. TEFCA can become the backbone of nationwide interoperability, or it can plateau as a well-intentioned framework that never fully reshapes workflows.
The difference will be leadership. Not policy. Not acronyms.
If you want TEFCA to matter inside your organization, now is the moment to move from awareness to execution.