Health IT Specification Set to Enable PCP, Specialist Care Coordination

Just as a circle has 360 degrees, Holly Miller, MD, MBA, FHIMSS, chief medical officer of MedAllies, says data exchange needs to be a closed loop process to enable care coordination.

That’s what she’s trying to accomplish with 360X, an ONC-backed effort looking to build data standards to enable coordinated and streamlined care between PCPs and specialists.

“360X specifications were created because the process of patient transitions of care, both transfers and referrals, continue to be fraught with risk of adverse events for the patient,” Miller, who is a part of the 360X work group, told EHRIntelligence in an interview.

For instance, when primary care providers (PCPs) refer a patient to a specialty provider, they send along relevant health information to help the specialist manage the patient’s needs. However, the PCP usually does not get information back from the specialist related to the patient, leaving the PCP to manually track their patient’s treatment.

“Referrals can be difficult to track and require excessive manpower for providers and staff if they want to ensure that their patients receive their necessary care and don't fall through the cracks,” Miller told EHRIntelligence in an interview. “Rather than manual tracking processes that may be missed or delayed, with 360X, every step is automated, so we always know what's going on with the patient.”

Miller explained that the first arc of the 360X specification circle includes the sharing of pertinent information from the referring or transferring provider to the referred or transferred provider.

“The second arc is the information returning to the sender and thereby closing the referral or transfer loop,” she said.

360X specifications use the Direct Standard, a widely adopted health IT procedure developed by non-profit healthcare industry alliance DirectTrust. Direct allows individuals to digitally send authenticated, encrypted health data to trusted recipients.

Integrating the Healthcare Enterprise (IHE) has approved 360X specifications for specialty referrals.

The 360X process for a specialty referral begins with a PCP specifying the physician or the group whom they want the patient to see. That information is sent to the specialist along with the reason why the PCP is sending the patient, the urgency of the visit, and pertinent patient health data.  

The specialty staff will review the request and accept or decline the notification based on whether the provider can see the patient in the timeframe that the PCP requested.

“The primary care staff will know immediately if the patient's been declined so they can find another specialist to send that patient to, who may be able to accept the patient,” Miller explained.

Miller noted that 360X specifications leverage FHIR scheduling, so that scheduling can be done immediately and the patient can leave the office with a specialist appointment. This limits the clinician burden of having to manually call the specialist office to set up an appointment.

Then, ideally the patient would present at the specialist appointment. This is what Miller referred to as “the happy path.”

“Clinical medicine is a push. When I'm sending a patient to another clinician, I want to send the information that I think is important for my colleague to be able to next manage the patient,” Miller said.

However, Miller noted that being able to pull data from sources is equally important.

“Say that the specialist doesn't have every piece of information they felt they need,” she explained. “For example, the PCP may not have known the patient had a given test of interest to the specialist, the specialist may be able to pull that from somewhere else.”

This allows providers to streamline care coordination for more efficient care delivery.

“If a provider has recently done tests on the patient, there's no need to redo the test, so you’re also reducing cost,” she said. “Most importantly, the patient doesn’t have to go through the inconvenience or discomfort of another test.”

After the specialist sees the patient, 360X specifications will send the PCP office the results of the consultation. If the specialist has ordered new medications or made new diagnoses, PCPs can pull that information into their EHR without documentation errors because it is discrete, standardized data, Miller explained.

This aids clinician burden, as providers automatically receive information instead of having to manually track their patient, she said.

“Your staff isn't making a bunch of phone calls because the data is sent and all goes directly into the EHR,” she noted. “You can incorporate the entire document coming in but also, very importantly, you can reconcile that critical discrete data in the recipient EHR. We're not at a point yet where things like lab data can be reconciled, but hopefully we're going to get there.”

If the patient doesn't present at the appointment, PCP office staff will get a no-show notification through an HL7v2 message. Then PCP staff can call the patient and find out why didn't she show up for the appointment to ensure she does not fall through the cracks and that she receives the care she needs.

In addition to specialty referrals, the IHE has also approved 360X specifications for ambulatory/acute transfers to skilled nursing facilities (SNFs). Recently, the 360X work group submitted a third use case for approval: transfers from SNFs to acute emergency departments (EDs).

“With the pandemic and the morbidity and mortality that was happening in nursing homes, we thought that was a very important use case to take on,” Miller explained.

The workgroup is also working on a use case for social determinants of health (SDOH) needs-based referrals. Miller explained that COVID-19 also helped jumpstart the work on this use case.

“With the pandemic causing unemployment in some sectors, we anticipated a great increase in people with social determinants of health needs,” she said. “Ultimately it's the same thing; you are identifying a referral need, making that referral, and then ensuring that the patient's needs have been met when the loop is closed.”

Miller said the 360X work group plans to submit the use case for IHE approval early this year.