California says goodbye to fax machines. Hello to DxF.

November 21, 2023
Jessica Bonham-Werling Head of Marketing

The fax machine has been the leading channel for healthcare information exchange for nearly 60 years, but those days are coming to a close in California. The California Health and Human Services Data Exchange Framework (CA DxF) is a novel statewide data-sharing agreement between healthcare providers, health plans, laboratories, government agencies, and social service programs. It was established through CA Assembly Bill 133 in 2021.

The CA DxF is designed to improve the quality, efficiency, equity, and coordination of care for Californians by making it easier for all entities involved in patient care to access the data they need to make informed care decisions.

CA DxF also expands a patient’s ability to access and control how their data is shared. Once live, patients will have the right to access their data, request that it be corrected/deleted, or even opt out of having their data shared.

Who must participate?

All general acute care hospitals, physician organizations, medical groups, skilled nursing facilities, health service plans and disability insurers, Medi-Cal managed care plans, clinical laboratories, and acute psychiatrist hospitals were required to sign the CalHHS data sharing agreement (DSA) by January 2023. A list of signing organizations is available here

When must they participate?

Most organizations must be ready to share data by January 31st, 2024. Small physician practices, rehabilitation hospitals, long-term acute care hospitals, acute psychiatric hospitals, small rural acute care hospitals, and nonprofit clinics will have until January 2026.

Consequences for non-participation are currently unclear, although providers may be cited for non-compliance with federal information blocking regulations which, according to the recent HHS proposed rule could be up to $1 million per violation.

Is this just another HIE?

A few features of the CA DxF set it apart from traditional health information exchanges (HIEs) and networks (HINs). Notably:

Data sharing purposes

Other data-sharing networks like Carequality are largely limited to “Treatment” purposes. CA DxF expands upon this, requiring participants to fulfill data requests for Treatment, Payment, Health Care Operations, and Public Health activity purposes. And, while not required, participants may also share data for social services and research activity purposes.

Data types to be shared

While the electronic exchange of clinical data is becoming more routine between healthcare entities, the exchange of social determinants of health data (e.g. access to housing and food) is less common. The CA DxF includes both clinical and social determinants data. The inclusion of social services organizations in the CA DxF is also unique as these entities are not recognized as healthcare providers under HIPAA and data sharing has been limited.

Additionally, under the CA DXF hospitals and emergency departments are required to notify any requesting participant of Admission, Discharge, and Transfer (ADT) events. Skilled nursing facilities will not be required to send ADT notifications at the time of CA DXF implementation, but are encouraged to do so.

Data exchange formats

CA DxF requires real-time data exchange, a notable difference from other data exchange networks. Required data format requirements are also notable.

At the time of implementation, the CA DxF will require USCDI v2 via Health Level Seven (HL7®) Clinical Document Architecture (CDA®), HL7v2, or Fast Healthcare Interoperability Resources (FHIR®) formats via health information exchange (HIE) profiles including:

  • Cross-Community Patient Discovery (XCPD) for patient search requests/response
  • Cross-Community Access (XCA) for requesting/sending clinical information

CA DxF also requires that participants support direct secure messaging via Cross-Enterprise Document Reliable Interchange (XDR).

Of note, the XCPD, XCA, and XDR profiles do not currently support FHIR natively. Any DSA signatory who wants to work in FHIR will likely need an intermediary to assist in translation to ensure outgoing data can be received by the requesting organization and incoming data can be harmonized and normalized alongside existing data.

Getting help

The novelty of CA DxF data sharing purposes and data types, its unique technical requirements, and quickly approaching deadlines will make it difficult for many DSA signatories to be compliant.

An intermediary can help. While there are 9 state-designated qualified health information organizations (QHIO), an intermediary is not required to be a QHIO, and signatories are not required to use a QHIO. When organizations are searching for help they should consider the security of a vendor’s solution and their experience translating and streaming data in real-time.

The Redox Solution

Redox Access can help DSA participants securely establish connectivity with CA DxF and meet all necessary data exchange requirements. The Access product has been built and refined over the course of nearly 5,000 Carequality and DirectTrust integrations, and nobody has more experience translating and streaming healthcare data at scale than Redox.

The table below is an overview of Access-provided features and services.

Platform Dashboard Features Managed Services
  • Managed Services
  • Connectivity to CA DXF
  • Bidirectional XCPD, XCA, and XDR data exchange
  • ADT events exchange
  • FHIR support
  • Platform API
  • Logging & Transaction Monitoring
  • Message Filtering Configurability
  • Enterprise Single Sign-On
  • User Management & Role-Based Access Controls
  • PHI Access Auditing
  • HITRUST and SOC Type 2 certified
  • Enterprise Onboarding Support
  • Technical Implementation and Maintenance Support
  • 24/7 Production Support
  • Testing Strategy Alignment
  • Connection and Workflow Expansion
  • Volumetric Performance Tuning
  • Quarterly Success Evaluation

The diagrams below are examples of how Redox can help enable DSA signatories. These are just examples and may vary based on the organization’s existing technical infrastructure and requirements.

Requesting and receiving ADTs for a defined set of patients

Requesting and receiving ADTs for a defined set of patients graph

Making patient search requests to the network

Making patient search requests to the network graph

Making and receiving DocQuery and DocGet requests to the network

Making and receiving DocQuery and DocGet requests to the network graph

Receiving documents from network participants (direct messaging)

Receiving documents from network participants (direct messaging) graph

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