As the California Health and Human Services Agency (CHHS) work with its Stakeholder Advisory Group on a Data Exchange Framework, the agency has indicated that it will look to the CalDURSA and its CTEN in constructing a single statewide data sharing agreement. This fact sheet provides an overview of the CalDURSA and CTEN and analyzes their potential role for data sharing under A.B. 133 and the Data Exchange Framework. 

What are CTEN and CalDURSA? 

CTEN refers to the California Trusted Exchange Network, a statewide network that links together data from various health information organizations and exchanges in California. CTEN participants have agreed to a common set of policies and procedures for sharing data, selected the data sharing transactions of interest, and completed CTEN testing for document exchange. CTEN is not itself a health information exchange but rather a mechanism for organizations to send and respond to queries for health information among each other. 

The common set of policies and procedures that underpin CTEN are contained in the CalDURSA, the California Data Use and Reciprocal Support Agreement.1 CalDURSA is the single data sharing agreement, supported by a series of policies and procedures that defines the behavior for sharing data among CTEN participants. 

The CalDURSA was last updated in 2014 and was developed based on the DURSA for eHealth Exchange, the nationwide network of networks. The policies and procedures are modified, added to and removed by vote of the CTEN Advisory Committee during monthly meetings and onboarding of participants. 

Nineteen organizations are party to the CalDURSA, including health information organizations, several health systems and government agencies.2 Sixteen of those organizations actively share data with each other, including 11 community HIOs, three health systems and two departments of the California Health and Human Services Agency.3 Statistics are not published on how many queries are made via the CTEN participants. 

Both CTEN and CalDURSA are maintained by the California Association of Health Information Exchanges (CAHIE), a statewide organization formed in 2013, with the primary objective “to establish voluntary and cooperative governance and guidance for trusted health information exchange in California.” 

What’s in the CalDURSA? 

Some key components of the CalDURSA include: 

• Interoperability Committee: Outlines the responsibilities of the Interoperability Committee established under the agreement, which include determining whether to admit new participants to CTEN, developing and amending the Operating Policies and Procedures, and receiving reports of data breaches, among other responsibilities
• Use of Message Content: Specifies that CTEN participants may only transact message content for a permitted purpose, and may retain, use or re-disclose message content only in accordance with applicable law
• Message Requests and Responses: Requires that message requests be for permitted purposes and submitted by participants with the authority to make such a request and who is the intended recipient; explains that participants have minimum requirement to respond to requests for message content for treatment purposes under HIPAA, but not for other purposes (e.g., health care operations and payment), these are left to the HIE participant decision; and outlines how participants must respond to requests;7 
• Privacy and Security: Requires compliance with HIPAA privacy and security regulations, requires breach notification to other participants whose data may have been breached and to the Interoperability Committee, and requires participants to have certain system access policies, enterprise security, and auditing processes;8 and 
• Other Key Items: Include detail on specifications, validation plan and testing, and operating policies and procedures.
• Key considerations in looking to CalDURSA and CTEN as a template for a state data exchange framework 
• CHHS has indicated through the Stakeholder Advisory Group that the CalDURSA’s framework for data exchange will be considered as the state looks to develop the Data Exchange Framework. While CalDURSA serves an important purpose in enabling data exchange for CTEN participants, it does not meet all the needs of the state and stakeholders to be able to create the robust, proactive data sharing environment envisioned under A.B. 133. 
• In considering the contents of the CalDURSA in developing the Data Exchange Framework, the CHHS Stakeholder Advisory Group should 
• Ensure that all HIPAA use cases are supported for data sharing, not just treatment purposes. The CalDURSA was designed as a technical and legal framework for a statewide network to query for individual health data. The CalDURSA focuses on “message content” particularly for treatment purposes and only requires responses to requests for treatment purposes, leaving out other payment and operations use cases under HIPAA. Leaving out all HIPAA use cases from the CHHS Data Exchange Framework would exclude many data sharing use cases important to meeting California’s health reform goals, including care coordination efforts conducted by health plans and sharing care plans with social services agencies under CalAIM, for example. 
• Account for real-time data sharing among organizations. The CalDURSA’s current participants are utilizing direct message requests from CTEN participants, not on real-time data sharing. The Agreement and underlying policies and procedures sets up a framework for CTEN participants to query the network for individual patient data, push individual data and ADT or other feeds to CTEN participants, government agencies and is similar to other national networks like eHealth Exchange and Carequality. This could provide the foundation for stakeholders to contemplate how data gets shared proactively in real-time under A.B. 133’s data sharing mandate, or other standards for data sharing, such as Fast Healthcare Interoperability Resources (FHIR). 
• Consider the participation of all government agencies, health care organizations and social services organizations and health plans. Many organizations key to supporting whole person care, public health and social health are not able to query or share data via CTEN because CTEN participants are primarily health information organizations and health systems in California. While DHCS and EMSA, two Departments of CHHS use the DURSA to share data with HIOs, mostly missing are state and county agencies, social services agencies and community-based organizations that have important health and social needs data important to the state’s health priorities, such as Medi-Cal Enhanced Care Management, school-based health services and public health promotion. While some health information exchanges do have participation from these types of organizations to varying degrees, their participation in health information exchange is not uniform across CTEN participants, and many counties have no local organizations participating in CTEN at all.