If you're a forward-thinking healthcare IT leader, you realize that interoperability is a business-critical imperative. With the Trusted Exchange Framework and Common Agreement (TEFCA) gaining traction in 2025, healthcare organizations are under pressure to modernize their data exchange strategies. The goal? Enable secure, real-time, nationwide data exchange while staying compliant with a growing list of regulatory requirements.

But here’s the challenge: aligning your cloud infrastructure to TEFCA isn’t just about plugging into a new network. It’s about rethinking your architecture from the ground up—especially when it comes to security, auditability, and consent management.

This blog offers a clear, actionable roadmap for healthcare IT leaders to build a TEFCA-ready architecture on Microsoft Azure. It outlines the core capabilities your system must support, provides architectural blueprints, and answers the tough questions CIOs, CISOs, and compliance officers are asking.

What TEFCA Requires And Why It Matters Now

Before building anything, it’s important to clarify what TEFCA actually demands from your IT infrastructure.

TEFCA compliance requires that your systems support:

• Connectivity to QHINs (Qualified Health Information Networks): Organizations must be able to interact with national data networks.

• Patient-centric exchange protocols: Support for query-based and push-based data sharing workflows.

• Security and trust: Use of FHIR, IHE profiles, mutual TLS, digital certificates, and end-to-end encryption.

• Audit and provenance tracking: Ability to log, trace, and verify every data exchange.

• Consent and access control: Honor patient preferences at scale and across organizational boundaries.

Failure to prepare could leave organizations sidelined as data-sharing expectations harden into requirements.

Architectural Overview: TEFCA-Ready by Design

A TEFCA-aligned cloud architecture on Azure must do more than simply meet compliance checkboxes—it should be scalable, secure, and ready for real-world operational demands. Here’s a high-level view of how to structure it.

Core Architectural Layers:

1. Data Ingestion and Normalization Layer

   • Tools: Azure API Management, Azure Logic Apps, Azure Data Factory

   • Purpose: Standardize incoming data from EHRs, partner systems, and devices (HL7, FHIR, X12, etc.)

2. Data Exchange and Interoperability Layer

   • Tools: Azure Health Data Services (FHIR, DICOM, MedTech), Azure Integration Services

   • Purpose: Enable standards-based exchange (FHIR, IHE) and map to TEFCA workflows

3. Security and Trust Layer

   • Tools: Azure Key Vault, Azure Private Link, Azure Firewall, Microsoft Defender for Cloud

   • Purpose: Ensure identity verification, encryption, and threat protection

4. Audit and Logging Layer

   • Tools: Azure Monitor, Log Analytics, Azure Policy, Purview

   • Purpose: Maintain traceability, detect anomalies, and meet provenance requirements

5. Consent and Access Control Layer

   • Tools: Microsoft Entra (formerly Azure AD), Azure Confidential Ledger, Custom APIs

   • Purpose: Manage dynamic, patient-centered access based on consent

Operational Foundations for TEFCA Alignment

Meeting TEFCA requirements isn’t just about compliance—it’s about answering some of the most pressing questions facing today’s healthcare IT leaders.

Let's break down the four foundational pillars every Azure-based TEFCA architecture must get right: security, auditability, consent, and qualified health information network (QHIN) connectivity. 

Security: Zero Trust as the Baseline

Question: How do we ensure data is secure as it moves through QHINs and external partners?

Answer: Adopt a zero trust architecture (ZTA) that assumes breach, verifies explicitly, and limits access based on real-time risk.

Best Practices on Azure:

• Identity First: Use Microsoft Entra ID with Conditional Access policies. Integrate multifactor authentication and device compliance checks.

• Encrypt Everything: Leverage end-to-end encryption with TLS 1.2+, encrypt data at rest with customer-managed keys via Azure Key Vault.

• Network Isolation: Use Azure Private Link to isolate traffic and eliminate exposure to the public internet.

• Threat Detection: Integrate Microsoft Defender for Cloud to monitor, alert, and respond to suspicious behaviors across hybrid environments.

Bonus Tip: Set up policy baselines in Azure Policy to enforce TEFCA-aligned controls automatically.

Auditability and Provenance: Build for Transparency

Question: How do we track and prove what data was exchanged, by whom, and under what context?

Answer: Implement detailed, tamper-resistant logging and observability systems across the architecture.

Azure-Ready Approach:

• Centralized Logging: Use Azure Monitor and Log Analytics to collect and correlate logs from APIs, databases, and integration layers.

• Immutable Ledger: Record audit trails in Azure Confidential Ledger for tamper-evidence and verifiability.

• Metadata Tagging: Enforce structured metadata tagging (e.g., encounter ID, data source, timestamp) at the FHIR resource level.

• Access Visibility: Track who accessed what data, when, and why via Entra ID logs and API telemetry.

This level of traceability not only supports TEFCA mandates—it builds trust with patients, regulators, and partners.

Consent Management: Honor Patient Preferences at Scale

Question: How do we operationalize patient consent in a distributed, interoperable environment?

Answer: Architect consent as a first-class citizen—dynamic, verifiable, and enforceable across APIs and data stores.

Azure Strategies:

• Consent Repository: Store digital consent artifacts in a structured, queryable format (e.g., FHIR Consent resources in Azure Health Data Services).

• Access Rules Engine: Create an API-driven service that checks consent records before releasing data.

• Audit-Backed Enforcement: Log all consent checks and denials using Azure Monitor to prove compliance.

• Edge Enforcement: Use Azure API Management to enforce consent policies at the request level—before the data ever leaves the system.

Emerging Practice: Integrate Decentralized Identity (DID) concepts using Microsoft’s Verifiable Credentials to give patients control over identity and consent artifacts.

QHIN Connectivity: Interfacing with the National Exchange

Question: What does it take to connect with a QHIN—and stay connected?

Answer: Your Azure architecture must support bidirectional APIs, rigorous authentication, and protocol translation.

Implementation Steps:

• FHIR-First APIs: Expose and consume FHIR APIs via Azure API Management and Azure Health Data Services.

• Protocol Bridges: Use Azure Logic Apps to translate HL7v2 or CDA to FHIR, or map IHE profiles.

• Authentication Support: Enable mutual TLS, JWT validation, and client certificate verification at the API gateway.

• Monitoring and SLAs: Set up automated alerting via Azure Monitor to detect dropped connections, failed exchanges, and latency issues.

Recommendation: Conduct a QHIN-readiness assessment and simulate end-to-end exchange scenarios before going live.

Common Pitfalls—and How to Avoid Them

Even the most well-funded teams run into roadblocks. Here are the top traps and how to sidestep them:

The Business Case for TEFCA Readiness

Beyond compliance, building a TEFCA-ready architecture on Azure delivers real operational and strategic benefits:

• Stronger data partnerships with payers, providers, and national networks

• Improved patient trust through consent visibility and data transparency

• Accelerated value-based care via timely, standardized data exchange

• Future-proof infrastructure ready for ONC, CMS, and HIPAA-aligned innovation

Think of TEFCA not as a mandate but as a market opportunity to lead in the interoperable, patient-centric future of healthcare.

Your Next Move

The TEFCA era is here. Healthcare organizations must move quickly but strategically to modernize their data architectures. While Azure provides the tools, it’s your blueprint, governance, and execution that will define success.

Action Steps:

1. Conduct a TEFCA readiness gap assessment.

2. Design a modular, scalable architecture using Azure reference patterns.

3. Start with high-impact use cases—like consent enforcement and audit logging.

4. Plan for continuous governance, not one-time compliance.

Need help aligning your Azure architecture to TEFCA?
Reach out to Productive Edge, a trusted Microsoft partner, to accelerate your journey. 

To get a deeper understanding of the Trusted Exchange Framework and Common Agreement, navigate to our recent blog on Understanding TEFCA: Key Changes and Impacts on Healthcare in 2025 and Beyond.