11 questions about TEFCA governance

The document describing the governance structure for our national onramp to interoperability dropped earlier today!

The Trust Exchange Framework Common Agreement (TEFCA) is intended to connect our nation's healthcare data exchange networks into a super network. If widely adopted, patient data could be accessible regardless of where it resides. The noble vision is to break down the data siloes.

When I saw the new Standard Operating Procedure (SOP) had been posted, I dove in comparing the governance structure described in the document with the version in my head. It's only 13 pages of content. Here is a link.

Governance Bodies & Advisory Groups 

The SOP describes three Governance Bodies and a potentially infinite number of Advisory Groups.

• The Governing Council: The permanent governing body for activities conducted under TEFCA. Its responsibilities include offering advice on onboarding and suspending QHINs and evaluating suspected non-compliance and security threats.

• The QHIN Caucus: A forum for Qualified Health Information Networks (QHINs) to meet and discuss TEFCA issues of interest and to vote on amendments to the Common Agreement, the SOPs, and the QHIN Technical Framework (QTF).

• The Participant/ Subparticipant Caucus: A forum for Participants and Subparticipants that belong to QHINs to meet and discuss TEFCA issues of interest. They can only vote on changes to the SOPs.

• Advisory Groups: Each Advisory Group's purpose is described in a separate charter. Their responsibilities may include providing feedback on the different aspects of TEFCA to the caucuses.

My TEFCA Governance Questions 

I'm hopeful... and I have questions.

1. If TEFCA has been live since 2023, why wasn't there a formal governance structure from the beginning? How can we ensure that there was no funny business between then and now?

2. The document describes QHIN and Participant/Subparticipant Caucuses, but how can we prevent self-dealing and disincentivize caucus members from colluding?

3. The Governing Council is composed of representatives from QHINs, Participants/Subparticipants, federal agencies, and the RCE. Who is representing patients' perspectives and privacy considerations on the council?

4. Why is there no patient caucus to ensure that this framework is designed for the benefit of commoners? My understanding is that the RCE’s consumer advisory group only convenes on an ad-hoc basis, and that it has no real authority.

5. Caucus members are expected to report to the chair of their governance body and to the designated Recognized Coordinating Entity (RCE) managing TEFCA and let them know if there is any potential or actual conflict of interest. If they are only "expected to" to disclose conflicts, why would they? And if they do not disclose a conflict of interest, are there consequences?

6. Thinking of QHINs that charge for certain services or that have other data exchange products, could they have a conflict of interest for any recommendations that have financial implications? What happens when many (or all) members of the QHIN caucus have a conflict of interest?

7. Members in TEFCA's governance bodies are expected to "preserve the confidentiality of all information to which they have access by virtue of their participation." How can we make the activities of the Governance Bodies as transparent as possible and avoid any perception that decisions are being made behind closed doors?

8. The document states that a simple majority (51%) is required in some circumstances and two-thirds in others, but what happens when a caucus votes one way on an amendment and the other caucus takes a different stance? And doesn't ASTP/ONC make the final decision anyway? Do the caucus votes carry any weight?

9. How can organizations participate if they have not signed the Common Agreement? For example, if a payer is reluctant to participate in TEFCA until certain changes are made, how would the payer provide input?

10. Are we moving too fast on these SOPs and not allowing adequate time to provide feedback before the final versions are released?

11. Does one caucus have more authority than the other? Do the Advisory Groups advise the caucuses that inform ASTP/ONC that makes the final determination?

I ask because competent governance is a requirement for trust in any data exchange network, and I want TEFCA to be successful.