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February 5, 2024 Readers Write No Comments

Would We Do It All Again? Insights from a Designated QHIN Regarding the Application Process
By Jay Nakashima

Jay Nakashima, MBA is executive director of EHealth Exchange of Vienna, VA.


I was asked recently, “Would we do it all again?” Knowing what we know now, would we still have been among the first organizations to apply to become a Qualified Health Information Network (QHIN) under the Office of the National Coordinator for Health IT’s (ONC) Trusted Exchange Framework and Common Agreement (TEFCA)?

Honestly, the answer is yes. But I’m glad it’s behind us.

There’s no doubt the QHIN process was a necessary step toward achieving nationwide healthcare interoperability. As the nation’s first federally endorsed health information exchange that already exchanges 21 billion transactions annually and in all 50 states, there was never a question whether EHealth Exchange would participate in the process.

But it was not always an easy and straightforward process to becoming one of the first Designated QHINs. As anyone who has developed a new system or process knows, what makes perfect sense in planning doesn’t always work out as intended. Unforeseen challenges pop up, and things need to be tweaked and adapted. We expected that.

Now that we’ve had a chance to take a breath and regroup after achieving QHIN designation, it seemed like a good time to share some thoughts and perspective to help others going through the application process.

The healthcare industry is slow to adopt new technology. After all, we’ve been talking about nationwide interoperability for more than 15 years, and while we have made great strides, it is not ubiquitous. The QHIN application process, by comparison, is incredibly fast. The timeline to accomplish various tasks can be remarkably short, sometimes only a few days or weeks in between deadlines. To keep up, an applicant must be prepared to move quickly because once an application has been accepted for testing, Candidate QHINs have 12 months to achieve designation status.

One thing that helped EHealth Exchange was that our team got started well before we entered the official application process. We looked at the proposed language in the QHIN Technical Framework (QTF), which was published in 2022, and spent more than six months ensuring that we closed any gaps between EHealth Exchange’s technology platform and our policies to ensure compliance with TEFCA requirements, standard operating procedures, and protocols. By the time the application was released, we were ready.

This process — and more importantly, the responsibility of becoming a QHIN — is not for the faint of heart. It was a two-year process for EHealth Exchange, and the work doesn’t stop after designation. For those entering the application process now, it’s worthwhile to review the requirements and begin tackling initial tasks before the clock starts.

Although the applicant QHINs were market competitors, we also were all working to achieve the same thing, which gave us a compelling reason to collaborate. Many applicants turned to each other for assistance, and we even began early testing together, unprompted by the government. Candidly, I thought that competition might hinder our abilities to work effectively together, and I am happy to say that that never surfaced. We were all a team working together toward a collective goal.  As others go through the QHIN application process, we would encourage a similar level of appropriate and compliant cooperation with your fellow applicants and Designated QHINs. After all, we all win with national interoperability. 

It’s always easier to drive on a freshly paved road, and I like to think that, along with our future QHIN exchange partners, EHealth Exchange helped pave the way for the next applicants.  As I said before, any new process – particularly one with the level of technical complexity that health data exchange demands – is going to run into unforeseen problems. And boy, did we encounter a lot of them. Steps have been refined. Some requirements have been clarified or adjusted, and new ones have been added. 

For example, each Candidate QHIN had to create its own terms and conditions. In Common Agreement Version 2.0, the Recognized Coordinating Entity (RCE) is proposing a standard set of terms and conditions that each QHIN, and its participants and sub-participants, must adopt to participate in TEFCA, which is a simpler and more consistent approach. The process is now better documented and defined, and I am optimistic that those changes will make it easier for other applicants. 

While I wouldn’t volunteer to repeat the journey we took, for new applicants, you should have no qualms undertaking the application process. Not only because it has been tried and refined, but also because I believe deeply in its value. I’m excited to see TEFCA come to life and to bring our experience to bear in support of our future QHIN exchange partners, the RCE, and most importantly, the American health system and the patients whose care depends on nationwide exchange.

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