HTI-4: TEFCA, E-Prescribing & Standards Transitions

HTI-4 is the next major rulemaking from ASTP/ONC, building on the HTI-1 foundation and the HTI-2/HTI-3 updates that preceded it. While HTI-1 updated the certification program and data standards, HTI-4 focuses on network connectivity and additional standards transitions.

The headline item is TEFCA — the Trusted Exchange Framework and Common Agreement. TEFCA creates a nationwide infrastructure for health information exchange, and HTI-4 proposes requiring certified health IT to participate in it. This is the piece that connects the dots between individual FHIR APIs and a functioning national health data network.

TEFCA — the Trusted Exchange Framework and Common Agreement — is a set of policies, technical standards, and legal agreements that enable nationwide health information exchange. Think of it as the interstate highway system for health data.

Before TEFCA, health information exchange was fragmented. Regional networks existed but didn't always talk to each other. Connecting to a hospital across state lines required custom integrations. TEFCA creates a common framework so that organizations connected to the network can exchange data with any other connected organization.

• Nationwide reach: Any TEFCA-connected organization can exchange data with any other, regardless of geography or network affiliation.
• Standardized trust framework: Legal agreements and policies are consistent across participants, reducing the negotiation overhead for each new connection.
• Query-based and event-based exchange: TEFCA supports both pulling data when you need it (query) and receiving data when something happens (event notification).
• Patient-centered: Patients can direct their data to flow between providers through TEFCA-connected systems.

HTI-4 includes several interconnected proposals. The specifics may change between the proposed and final rule, but the direction is clear:

• TEFCA Onboarding Requirement: Certified health IT developers would need to onboard to TEFCA by December 31, 2027. This means connecting to a Qualified Health Information Network (QHIN) and participating in nationwide exchange.
• E-Prescribing Standards Update: Transition to NCPDP SCRIPT v2023011 by January 1, 2028. This modernizes electronic prescribing with better support for specialty medications, prior authorization integration, and real-time benefit checking.
• USCDI Expansion: Additional data classes and elements building on USCDI v3, further expanding the standardized data set for interoperability.
• Enhanced API Requirements: Further refinements to FHIR API certification criteria, potentially including bulk data access and more granular consent management.

TEFCA changes the game for care transitions and referral coordination. Today, when a hospital discharges a patient to a home health agency, the data exchange is typically manual — fax, phone, or a custom integration with that specific hospital. TEFCA creates a world where any hospital connected to the network can send structured referral data to any home health agency on the same network.

For home health agencies, the practical implications include:

• Referral data arrives structured and complete: Instead of a faxed face sheet, you receive FHIR resources with clinical data, medications, diagnoses, and social determinants — all in a standardized format your system can parse.
• Care coordination becomes bidirectional: You can send visit summaries, medication changes, and clinical updates back to the referring hospital through the same network. The hospital doesn't have to call you for status.
• Multi-provider coordination improves: When a patient has a PCP, specialist, hospital, and home health agency, TEFCA enables all of them to access a common record instead of maintaining separate, conflicting information.
• New referral sources become accessible: Hospitals you've never worked with before can find you through the TEFCA network and send referrals electronically. Geography and existing relationships become less of a barrier.

The transition to NCPDP SCRIPT v2023011 may seem like a technical detail, but it has real operational impact for home health agencies that manage medication workflows.

The updated standard supports better integration between prescribing and prior authorization. When a clinician prescribes a medication that requires prior auth, the system can initiate the authorization request as part of the prescribing workflow instead of as a separate, disconnected process.

It also improves real-time benefit checking, so clinicians and patients know medication costs and coverage status before committing to a prescription. For home health patients managing complex medication regimens, this reduces surprises and improves adherence.

HTI-4 is still being finalized, so specific requirements may shift. But the direction is clear enough to start preparing:

• Ask your vendor about TEFCA readiness: Are they planning to connect to a QHIN? Which one? What is their timeline? If they don't have answers, that tells you something.
• Evaluate your data model: TEFCA exchange works best when your internal data model aligns with USCDI standards. Systems built on proprietary data formats will struggle to participate effectively.
• Think about your referral strategy: When any hospital can send you a referral electronically through TEFCA, your referral network expands dramatically. Is your intake system ready to handle structured referrals at scale?
• Plan for bidirectional exchange: TEFCA isn't just about receiving data — it's about sending it. Can your system generate standardized clinical documents (visit summaries, care plans, medication lists) that can flow back to referring providers?
• Monitor the final rule: HTI-4 is expected to be finalized in 2026. The final version may adjust timelines or requirements based on public comments. Stay informed.

HTI-1 set the data standards (USCDI v3, updated APIs). The CMS rule requires payers to open prior authorization APIs. HTI-4 connects the networks through TEFCA and modernizes prescribing workflows. Together, these three rules create the infrastructure for a fundamentally different healthcare operating environment.

By 2028, the agencies that embraced this transition will operate in a connected ecosystem — receiving structured referrals, submitting electronic prior authorizations, exchanging clinical data with hospitals and PCPs, and coordinating care through standardized APIs. The agencies that didn't will still be faxing.

The regulatory timeline is not a threat. It is a map. The agencies that read it early and move first will define what modern home health operations look like.