Eliminating paper, faxes and phone calls from the referral process has proven to be a stubborn interoperability challenge to solve, but health IT experts are still working on it. This spring, a Portland, Ore., primary care clinic and a behavioral health group will begin piloting the 360X closed-loop referral management tool embedded in their Epic and Netsmart EHRs.
Several speakers gave updates on 360X at the March 9 meeting of the Office of the National Coordinator for Health IT’s Health IT Advisory Committee (HITAC).
Brett Andriesen, infrastructure branch chief in the Office of Technology at ONC, explained that the work on 360X was launched way back in 2012, as part of the State Health Information Exchange cooperative agreement program. “The goal was to enhance referral management across different EHR vendor products. It has since been extended to include additional care transitions,” he said.
In electronically closing the loop on referrals, 360X hopes to improve patient, caregiver and provider satisfaction and enhance the efficiency and value of patient care while decreasing provider burden, transcription errors and the cost of care. The idea is that EHR vendors will add this functionality into their systems and make this generally available to their provider customers, who in turn will broadly deploy and adopt 360X functionality.
The effort used standards that are ubiquitous across the industry, Andriesen said. These include:
• HL7 C-CDA for clinical content
• The Direct Standard for transport
• XD for establishing context (metadata)
• HL7 V2 messages for referral/transfer status messages across care environments.
The Multnomah County Health Department in Portland is a customer of OCHIN, which offers a hosted version of Epic to community health centers. It will pilot sending referrals to behavioral health provider LifeWorks Northwest. They have a plan to go live in the second quarter of 2023. “Currently, we're testing the referral workflows of accepting and rejecting notifications for when a referral is received by the behavioral health provider, as well as closing the loop so that the clinical note is sent automatically after an appointment is completed,” said Ben Rosen, B.S.N., R.N., client success manager at Netsmart, whose EHR is used by LifeWorks Northwest. “Not only will you be getting a notification of the appointment being completed, but also the clinical note with some with a progress note and some update medications or clinical data pieces that will be sent automatically as well.” He said they would measure the time saved and reduced use of paper in the referral process over time.
Holly Miller, M.D., M.B.A., chief medical officer at MedAllies, described the process: Sending organizations push the required clinical information to the recipient; the recipient organizations, having seen the patient, send timely information back to the initiator, closing the loop. “All messages are sent electronic electronically, eliminating faxes and decreasing or eliminating phone calls,” she said. “The recipient can either accept or decline the referral. If the appointment or transfer is accepted, the office staff can go on to schedule the appointment or admission. If the request is declined, the initiating staff can quickly move on to make the request of another organization. Once the appointment is scheduled, real-time status information can be exchanged, so that both sides of the referral or admission process are always informed of the status of the patient.”
To date, the 360X work group has two use cases approved as Integrating the Healthcare Enterprise (IHE) approved Profiles:
• Referral Management
• Ambulatory/Acute transfer to a Skilled Nursing Facility (SNF).
A third use case involving transferring from SNFs to acute emergency departments (EDs) has been submitted for IHE Profile approval. The group is currently focused on the pandemic-relevant use cases of:
• Social Determinants of Health (SDOH) needs-based referrals and
• eConsults (a provider asking a specialist provider a question regarding a specific patient without, at least initially, referring the patient to the specialist).
Vendors actively working on the project include Altera Health, eClinicalWorks, Epic, Feeding America, MatrixCare, MedAllies, Meditech, Netsmart, NextGen, Kno2, Open City Labs, and Unite Us.
