Did you know that just one national network exchanges over 360 million clinical documents per month? Connecting to national networks like eHealth Exchange, Commonwell Alliance, and Carequality is by far the most popular topic of conversation with our clients and prospects. And with TEFCA moving ahead rapidly there has never been a better time to be sure you understand the existing national networks for trusted healthcare data exchange.

Understanding Trusted Exchange Frameworks


An often misunderstood area is the difference between a trusted exchange framework versus an exchange network. 

A trusted exchange framework is designed specifically to support a “network of networks”.  An excellent example is Carequality. Carequality has governance, shared business terms, and published implementation guides that multiple networks agree to follow so that they can exchange data across the networks. Today – Carequality is the trust framework underpinning a large volume of document exchange across a wide range of networks, including Carequality Implementers (Vendor Networks / HIEs) and large national trusted exchange networks such as Commonwell and eHealth Exchange. For simplicity, we are including Carequality in our network comparison below, as healthcare organizations can join any one of the three organizations and participate in national trusted data exchange via the Carequality Trust Framework.


TEFCA – a new federal (ONC) Trusted Exchange Framework


TEFCA was mandated by the 21st Century Cures Act in 2016. Similar to Carequality, TEFCA is a trusted exchange framework designed to support a “network of networks”. Qualified Health Information Networks (QHINs) are the data exchange networks that will be operating under the TEFCA trust framework. 

The ONC has designated a Recognized Coordinating Entity (RCE) – The Sequoia Project to oversee the implementation of TEFCA. The Sequoia Project was the original incubator for both the Carequality and eHealth Exchange organizations and therefore extremely experienced in building trusted exchange networks in healthcare.  And building on the success of the Carequality trusted exchange framework, the Carequality team is advising the RCE on technical and operational best practices, ensuring all those “lessons learned” help advance data exchange under TEFCA. For the latest announcements from the RCE regarding TEFCA and QHIN’s, check out their news site.

Why do we need two trusted exchange frameworks?


It is understandable that Congress wants to ensure that the U.S. has a long-term strategy in place for nationwide interoperability. With a trusted data exchange framework overseen by the Office of the National Coordinator (ONC), and through the work of the designated RCE there is now an even more sustainable path to nationwide data exchange. 

For now, TEFCA participation is optional, even though HIPAA-compliant data sharing is not optional, as established under the information blocking rules instituted under the 21st Century Cures Act. However, participation with any trusted exchange network, is extremely valuable, and a great demonstration of your healthcare organization’s willingness to share data under a well-established data-sharing agreement.


What are National Trusted Exchange Networks? 


Understanding reciprocity: The success of nationwide data exchange relies on the willingness of participants to share data, not just ask for data. You will see requirements in data sharing agreements that if you are making Treatment queries, you must also respond to Treatment queries.

National Trusted Exchange Networks look similar to “trust frameworks” in that they typically have:

  • A technical framework for sharing that data between participants
  • An onboarding or certification process 
  • Issuance of trust certificates to enable the exchange of data across the network
  • A published Directory of participant endpoints
  • Annual participation fees apply to certain types of participants. Generally, these fees are based on annual revenues.
  • Network Onboarding fees if you join the network directly (versus through an intermediary). Note these fees can vary widely between networks so it’s an important component to understand.

However, networks typically have some sort of common technology that is being used to facilitate the data exchange between the participants, and the participants can “opt in” to frameworks such as Carequality (or TEFCA if they become a QHIN) to share data across other networks. The amount of governance within a network varies depending on the specifics of each network. 

As we discussed above, the largest national trusted exchange networks are eHealth Exchange, Carequality and Commonwell Alliance. Understanding the details of each of the major organizations can be quite challenging, so let’s look at the differentiators between the networks. (Note that we are not including the widely deployed DirectTrust network since most healthcare organizations are very familiar with it and it is most typically used for secure messaging. It is notable that DirectTrust is now issuing the certificates for several of the networks below.)


Comparing eHealth Exchange, Carequality, and Commonwell


1. Carequality


As a trusted exchange framework, Carequality is certainly unique among the three networks. Carequality was the first trusted exchange framework to support “cross network” exchange. Members of the other networks can “opt-in” to Carequality and exchange data across all three networks.

A key concept to understand when considering Carequality participation is whether or not your organization is a Candidate Carequality Implementer. While this definition can be nuanced, a good rule of thumb is that healthcare vendors, HIEs, and payers are Candidate Implementers, and thus subject to Carequality annual participation fees. If your organization is delivering healthcare services to patients, you are not a Candidate Implementer. A great example of a Candidate Implementer is a healthcare IT vendor like Cerner, Epic, Nextgen (etc). These vendors are the Carequality Implementers who provide access to their healthcare provider clients.  Other types of healthcare IT vendors are also Candidate Implementers.  For example,  Patient Health Record Vendors who provide patients with access to their data.


2. eHealth Exchange


eHealth Exchange is one of the most mature networks, being the first IHE-based “query and response” national network in the United States. However, all three networks now have high participation rates. 

Today, a key differentiator for eHealth Exchange is the ability to exchange data with federal partners (SSA, DOD, VA). However, that will soon change as the federal partners have worked with Carequality to modify the data-sharing agreement so that it supports federal partner requirements. This will allow the federal partners to opt into Carequality participation. 

In addition, many of the nation’s most successful regional and state HIEs are eHealth Exchange members. If HIE access in multiple states is important to you, we highly recommend joining eHealth Exchange.

eHealth Exchange participants have the option to “opt-in” to Carequality for cross-network exchange. eHealth Exchange has stated its intention to apply to become a QHIN.


3. Commonwell Alliance


Commonwell Alliance was founded in part by Cerner, a major hospital vendor, although their vendor participation list has grown considerably. Commonwell includes a technology that supports Record Locator Services (RLS) and EMPI (Patient Index), which can help improve the success of queries within the Commonwell network. 

Commonwell participants have the option to “opt-in” to Carequality for cross network exchange. Commonwell has stated its intention to apply to become a QHIN.


Technical Considerations


On the technical side, all three of the networks share a very similar technical framework in that they rely primarily on the XCA / IHE standards to exchange documents. 

The most common use case is called query based exchange. In this data flow, a provider performs a patient query, reviews an available document list, and then retrieves the desired documents.

Documents are primarily CCD based XML documents but could be PDFs or other formats. FHIR as a data exchange standard is being piloted now and we expect to see a gradual movement to FHIR-based exchange, but for now, FHIR adoption will probably be focused on newer use cases, versus the widely adopted query based exchange.

Treatment is the most widely supported permitted purpose. Other purposes of use are available but have lagged behind in terms of widespread adoption. There is significant effort being made by network workgroups to modify terms or implementation guides to encourage the adoption of other important use cases such as the Patient Request, and payment/operations.

Given the maturity of the networks, you can expect to see new use cases being adopted as they move through the pilot stage. For example, under Carequality, Encounter Push Notifications is a relatively new use case that just moved into production. There is also an Imaging Pilot underway and Zen has a client participating using our Gemini + Stargate Integration as a Service platform.


Implementation Guides:


Implementation Guides provide very important information to prospective participants. 

Carequality Implementation Guides:

eHealth Exchange Implementation Guides:

Commonwell Services Specification Guides:


Barriers to participation in the Networks


Healthcare organizations often find the national trusted exchange network landscape difficult to navigate. Which network is right for my organization?  What are the best use cases?  Under what terms and conditions can data be exchanged? What is the cost of participating based on my organization type? Does my staff have the bandwidth to handle the technical onboarding and security requirements?  Can our technology even support the data connectivity requirements?


Implementers and Service Providers Help Address the Barriers


Implementers and Service Providers like Zen Healthcare IT exist to help your organization through the complicated landscape of national trusted exchange. During the sales process, we can help analyze your needs and match those up with the appropriate network. And our technology and technical services make onboarding much faster and easier.



National Network Onboarding With Zen’s Stargate Solution


Zen offers a robust, fully hosted, and managed gateway solution called ‘‘Stargate’, which serves as a single point of contact for National Trusted Exchange Networks like Carequality and eHealth Exchange. To ensure the highest level of security, Stargate is HITRUST CSF R2 certified. Stargate works with Gemini adaptors that are customized to integrate with EHR’s, CDR’s, and other healthcare vendor applications. Stargate also has APIs available.
Our Adapters are designed to facilitate a variety of integration patterns. This removes the need for expensive internal development projects. Whatever the best integration method is for your technology stack, Stargate will do the work to translate to the message protocols required by the national networks.

Network Onboarding Services:  


  • Zen team members are subject matter experts in onboarding clients to the national trusted exchange networks, removing that burden from your team.
  • Zen is also an official Carequality Implementer. This means that Zen clients can join Carequality through Zen as the Implementer. This greatly reduces the amount of work and effort required for onboarding.
You can be confident that with Zen, you have a partner that truly understands the nuances of implementing national trusted exchange use cases. This means better outcomes for your organization.
Want to learn more about how Zen can connect your organization to national networks or solve other difficult healthcare data interoperability issues? Schedule a free consultation with one of our interoperability experts today!

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