A county health director I spoke with two years ago described her data pipeline as a set of point to point agreements, one with each hospital system in her jurisdiction, each with different formats and different lag times. Getting a single case report sometimes took a phone call. That is precisely the fragmentation that the Trusted Exchange Framework and Common Agreement, known as TEFCA, was designed to dissolve, and by the second half of 2026 there is enough volume moving through the network to say the approach is working at a scale that matters.
Figures presented at this year's ASTP annual meeting show more than 474 million documents have been exchanged through TEFCA since its go live in December 2023, with annual document volume climbing from roughly 10.4 million in 2024 to a substantially higher figure in 2025. The framework, run by the Assistant Secretary for Technology Policy, formerly the Office of the National Coordinator for Health IT, now functions as what its architects call one connection to access all trading partners at nationwide scale, replacing the old model of separate bilateral agreements between every pair of health systems, labs, and now public health agencies.
A New Procedure Built Specifically for Public Health
The more consequential development for the public health community is a new TEFCA procedure designed to facilitate enhanced exchange of public health data, described by the Network for Public Health Law as addressing a persistent gap. Historically, TEFCA's core exchange purposes were built around treatment, payment, and operations, the categories that hospitals and payers use most. Public health reporting, which includes things like notifiable disease case reports, immunization registries, and syndromic surveillance feeds, sat awkwardly outside that structure, often requiring separate legal agreements even when the underlying data was already flowing through a TEFCA connected network for clinical purposes.
The updated procedure gives public health authorities a defined path to request and receive data through the same Qualified Health Information Networks, or QHINs, that hospitals already use, without each health department having to negotiate its own bespoke connection. For a state epidemiologist, this means a hospital already exchanging records for treatment purposes can, under the new procedure, also serve as a source for a case report or an immunization update without a duplicate integration project. NACCHO, the association representing local health departments, has published guidance for its members explaining the version 2.1 update and what it means for jurisdictions weighing whether to connect directly or work through a state level intermediary.
Why This Matters More Than the Headline Volume
The document count is a useful proxy for adoption, but the structural change matters more for long term cost. Every additional bespoke interface a health department maintains is a piece of software that needs its own testing, its own vendor relationship, and its own failure mode when a hospital changes its electronic health record vendor. A public health authority that can rely on a single TEFCA connection to reach multiple hospital systems reduces that maintenance burden meaningfully. It also means that when a new hospital joins a QHIN for entirely unrelated clinical reasons, the public health data pathway comes along automatically rather than requiring a fresh negotiation.
This is the same pattern that played out in health information exchange more broadly over the past decade, where the initial investment goes into standards and legal agreements, and the payoff arrives later as more participants join and the marginal cost of each new connection drops toward zero. TEFCA's growth from 10 million documents in 2024 to a much larger 2025 total suggests the network is now past the early adoption phase where growth is slow and uncertain, and into the phase where each new QHIN and each new participating health system adds compounding value for everyone already connected.
The Practical Questions for Health IT Vendors
Companies building population health and surveillance software should watch two things closely. First, which QHINs are actively supporting the public health exchange purpose, since not every network operator will prioritize this use case at the same pace. Second, how state health departments choose to connect, whether directly as TEFCA participants or through a state designated intermediary such as a health information exchange organization that already aggregates data on their behalf. The intermediary path is likely to be more common in the near term, because most state health departments do not have the technical staff to manage a direct QHIN relationship, and existing state HIEs already have that infrastructure and the vendor relationships to support it.
There is also a data quality dimension that deserves attention before anyone declares victory. Moving more documents through a standardized network does not automatically mean the documents are complete, timely, or correctly coded. Case reporting has struggled for years with inconsistent use of standard vocabularies, and connecting more sources through TEFCA increases the volume of data flowing without necessarily fixing that underlying quality problem. The next phase of this work, likely to unfold through 2027, will need to focus on data quality tooling as much as connectivity.
Key Signals
TEFCA's climb past 474 million cumulative documents exchanged, alongside a dedicated public health data exchange procedure released this year, shows the national interoperability framework maturing from proof of concept into working infrastructure that public health agencies can actually rely on. The practical benefit for health departments is fewer bespoke integrations and faster onboarding when a new hospital or lab joins an existing QHIN. Most state and local agencies will likely connect through intermediaries rather than directly, which keeps demand strong for health information exchange organizations with public health specific tooling. The unresolved question going into 2027 is whether higher document volume will be matched by improvements in the underlying data quality and coding consistency that public health surveillance actually depends on.
