Welcome to 360X: Closed Loop Transitions of Care Project


Problem: Despite major advances in Health Information Technology (HIT) and adoption thereof, the process of patient transitions of care (both transfers and referrals) continues to be fraught with risks of adverse events for the patient due to insufficient information at the time of the care transition.  In addition, transitions continue to be difficult to track and require excessive steps and manpower for providers and staff, and still does not ensure that patients receive necessary care and do not fall through the cracks. 

360X is a series of IHE approved, and in process, specifications that describe functionality to be deployed directly from the initiating (referred or transferred by) clinical EHR to the receiving (referred or transferred to) clinical EHR to track patient care transitions across the spectrum of care.  360X requires only ubiquitously adopted technology standards, therefore, represents a relatively low bar for EHR development and implementation. It is important to note that the 360X specifications are freely available, and are themselves not a product.

Currently multiple large market share EHR vendors are in the process of deploying this functionality, others have added it to their product road map.  Please ask your EHR vendor about their 360X plans.


In July 2012, 360X launched as an initiative of ONC’s State Health Information Exchange Cooperative Agreement Program, a component of the American Recovery and Reinvestment Act of 2009 with a goal of supporting states’ efforts to rapidly build capacity for exchanging health information within and across state lines. Specifically, the mission of 360X was to “as quickly as possible using proposed Meaningful Use Stage 2 standards, enable providers to exchange patient information for referrals from their EHR workflow, regardless of the EHR systems and/or HISP services used (i.e., allowing information to move point-to-point between unaffiliated organizations, differing EHRs, and differing HISPs) and with at least the same quality of workflow integration providers currently experience when referring between homogeneous EHR systems.”

Since its inception, the 360X project has had input from a broad representation of roles throughout the public and private sectors.  The group includes clinicians, technical experts, with representation from many EHR and HIT vendors, and ONC representatives.

360X builds on the ability of certified EHR systems to push, in real time, at the time of the referral or transfer request, C-CDA documents containing discrete data using standardized vocabularies (such as USCDI) as required by CMS incentive programs.  This enables the receiving system/end user to pull the discrete data into the chart, reducing clinician transcription burden and eliminating transcription errors.

The initial goals were to:

  • standardize the type of data exchanged and method of transport –achieved with C-CDA and Direct transport
  • have transparency between the referring/transferring provider and the referred/transfer organization regarding progress of the process and gaps in care – achieved with standardized HL7v2 messages
  • create a process with a low technical bar for entry and implementation to create broad rapid adoption across EHR vendors and clinical organizations – all standards are ubiquitously adopted
  • referral/transfer order assigned a global unique identifier that persists until the referral/transfer loop is closed. This specific referral number facilitates the EHR systems to readily identify and associate the communication across systems with the relevant patient.
  • add value to patients, clinicians, office staff and overall clinical workflows



360X for Referral Management is an IHE approved specification (profile)


  • Currently in the process of being implemented by several leading market share EHR vendors

Acute or Ambulatory Transfer to Skilled Nursing Facility (SNF) also now an IHE approved specification (pending official publication)

  • Currently in the process of being implemented by several leading market share LTPAC EHR vendors

In Process

These use cases were selected by the group due to their particular relevance during the COVID-19 Pandemic

360X for SNF to ED Transfer

  • Has been submitted to IHE to begin the approval process

360X for SDOH Referrals from a clinician/provider organization to a Community Based Organization (CBO) or to an SDOH Referral Hub for distribution to a CBO

  • Development in process

Join Us

To join the project group, contribute to improving the specification, defining the new use cases or get implementation questions answered, please contact Brett Andriesen.

You can join the contributor mailing list by entering your e-mail on the list information page or by sending an e-mail to 360x-contrib-join@360x-referral.com with a subject of subscribe from you preferred e-mail account. Please make sure that an overzealous spam filter is not holding any responses to your subscription request.

For more information about how 360X works, view the latest version of our Implementation Guide. 
For the latest news, visit the Blog area

The following recordings of live demos showcasing the benefits of 360X are available:

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